CLINICAL INTERNSHIP REPORT

(PSYI619)

(Neurotic Cases)

Post-traumatic Stress Disorder & Obsessive Compulsive Disorder

(Internee)

Student Name : Shahid Siddique

Student ID : BC190201399
(BS Psychology)

2019-2023

Submission date : 07 February,2023

Virtual University of Pakistan

___________________________________________________
Department of Psychology,
Virtual University of Pakistan

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 Acknowledgement

I would like to appreciate the management of Virtual University and Cheema Heart
Complex and General Hospital, Gujranwala, for providing resources and establishing
environment to conduct the internship. I also appreciate my teachers, fellows and
respondents for their constructive contributions to accomplish the internship
accordingly.

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Letter of Undertaking Certificate

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Internship Completion Certificate

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 TABLE OF CONTENTS

Pag
S. No. Contents e
No.
1 Clinical Case Report 1st 6
Background/ information history 6
Reason and source of referral 6
Presenting complaints 7
History of present illness 7
Family history (parents) 7
Educational history 8
Social history 8
Medical and psychiatric history in family 8
Psychological assessment 8
Informal Assessment 8
Formal Assessment 10
Personality Test 11
Diagnosis 12
Case formulation 12
Prognosis 13
Management plan 13
Therapeutic Interventions 13
Appendences 17

2 Clinical Case Report 2nd 22

Background/ information history 22

Reason and source of referral 22
Presenting complaints of the patient 23
History of present illness 23
Personal history: 23
Family history 24
Premorbid (before issues) personality 25
Medical and psychiatric history in family 26
Psychological assessment 26
Informal Assessment 26
Formal Assessment 27
Personality Test 28
Diagnosis 29
Prognosis 29
Case formulation 29
Treatments and therapies 29

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 Appendences 34

Neurotic Cases
1. Post-Traumatic Stress Disorder

Background/ Information History

The client’s name is G.M. The client gender is Male. His age is thirty-five years
old. He was married. His birth order is 1 st. He has two siblings (one brother &
one sister). Client’s wife is no more. He belongs to nuclear family. He belongs to
middle class socioeconomic status family. Client is himself informant.

Name G.M

Age3 35 years
Gender Male
Education Matric
Weight Status 50kgs
No of siblings 2
Birth order 1st
Religion Islam
Informant Client himself
Reason and Source of Referral

The client is feeling abnormal since two years after the death of his spouse. He
took different types of medicine but cannot recovered himself. The client then
decided to consult a psychiatrist. The client came with the complaints of lonliness,
sleeping issue, overthinking, overeating, fear of something going wrong,
restlessness. The client reported at Cheema Heart Complex Client where he was
initially checked by medical specialist and then referred as he was a psychological
case. He was referred for the sake of psychological assessment and management
by Cheema Heart and Complex Center Psychological ward.

6
Presenting complaints

According to client
Duration Presenting complaints
2‫سا ل‬ ‫نیند نہیں آتی‬
1 ‫سال‬ ‫کچھ غلط ہونے کا ڈر‬
2‫سا ل‬ ‫بے چینی‬
2‫سا ل‬ ‫افسردہ رہنا‬
1 ‫سال‬ ‫کا دل ت‬
‫کرتا ہے‬ ‫نرہنے ن‬ ‫اکیلے‬
1 ‫سال‬ ‫چک ھ کرے کو دل ھی ں کر ا‬

History of Present Illness

According to client, he was married 15 years ago. He was spending happy life
with his life partner. The relation with his siblings is also normal. He met an
accident and that cause loss of his wife. He has one kid at that time having age of
12y. This male kid went with his grand-parents. So this thing made him complete
lone. He has to face different challenges like sexual needs, home caring, cleaning,
cooking and eating. He hired a servant but not satisfied with performance. He
started suffering from restlessness since two years. He always feels fear of being
something wrong from him. He feels restlessness and sadness. He started drinking
wine to rid of from tensions. He always wants to live at rest/no work. This all
happens after the death of his spouse. The second main reason is he belongs to
nuclear family and his son also left him and living abroad with grand-parents.

Family history (Parents)

The client belonged to a middle socioeconomic status. They lived in a nuclear

/single family system. Client’s parents were alive. He had good relation with his
family sometimes his mother became strict according to situation. The client
stated that his parent’s marriage was arranged. He also mentioned his relationship
with his father was very good and he was very loving. His parents were happily
married. His mother was a housewife and father was a businessman. He had one
younger sister.

Educational History

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He took admission in Govt. school at the age of 5 years. Client did take religious
education and he completed her Holy Quran. He was happy at that time period.
The client reported that he was an average student. The client also participated in
extracurricular activities. He had good relationships with his teacher and fellows.
According to the client, he had few friendly relations and only used to play with
them. He did metric from the private school.

Social History:

The client was introverted in nature. The client reported that he didn’t have many
friends. He didn't have a big social circle of friends. He was not very active and
sociable. He isolated himself and he also experiences loneliness from the last 2
years.

Medical and Psychiatric History in Family

The client family had no medical history of any psychological disorder.

Psychological Assessment

Psychological assessment was done on both formal & informal level using the
following measures:

Informal Assessment

Informal assessment is a non-Standardized procedure for obtaining information

that can be used to make judgments about a client's problematic behavior and
characteristics (Cowen, 2006).

Clinical Interview

The clinical interview was the most fundamental component of counselling,

psychiatry and psychology and was a basic unit of connection between the helper
and the person seeking help. It was the beginning of a therapeutic relationship and
the cornerstone of psychological assessment (Jones, 2010; Sommers-Flanagan,
2016).

One of the main roles of a psychologist was to conduct clinical assessments to

determine whether a client was suffering from a psychological or behavioral
disorder. During the clinical interview, a psychologist would gather information
regarding a client's family history, social life, employment, financial situation,

8
previous experience in mental health treatment and other factors that could impact
on mental health and well-being. The interview was helpful in eliciting
information that was later helpful in making a conceptualization of his case for
better treatment. This type of interview was carried out in the first 3 sessions and
formal assessment also was carried out. Question was asked for the diagnostic
purpose and an informal assessment was completed in this manner. By the clinical
interview, detailed information was gathered regarding illness.

Mental Status Examination (MSE)

A mental status examination (MSE) is an assessment of a patient's level of

cognitive ability, appearance, emotional mood and speech and thought patterns at
the time of evaluation. It is one part of a full neurologic examination and includes
the examiner's observations about the patient's attitude and cooperativeness as
well as the patient's answers to specific questions (Eisendrath, 2001).

According to the Mental Status Examination, the client was a 35 years old male of
good height and weight. At the time of examination, he was not very talkative and
answered each question to the point. His dressing was fine. He was wearing a neat
and clean dress of seasonal appropriateness. His hair was combed well. The color
of the client's hair was brown and the texture was a little good. His hygienic
condition was also fine. During the interview, he was seated comfortably. The
client was not maintaining eye contact when asked about his family relations at
first. His attitude during the interview was cooperative. His facial expressions
were normal until he was asked about his mothers’ death. The client was an
introvert. He was very shy at first. He reported that his sleep is disturbed. He sat
on the chair confidently. He was not very conscious about his appearance. The
volume of the client’s speech was fine. No stammering or stuttering was observed
until he talked about the behavior of his brothers. His content of speech was
appropriate. No hallucinations or delusions were observed. Memory functions
were intact with respect to recent, immediate and remote recall of events. His
abstract thinking was good. His general knowledge was excellent. The client
clearly lacked in abstract thinking. He was able to tell the meaning of proverbs.
Client had good orientation because when he was asked about his doctor name,
general knowledge and about the world his answers were correct. He had good
insight about his present state of illness.

9
Formal Assessment

It is a type of clinical assessment in which the doctor uses standardized tests in a

structured to assess the patient. For example, a questionnaire with multiple
questions and possible answers (optional) is created and used to interview the
patient.

Beck Anxiety Inventory

The Beck Anxiety Inventory (BAI), created by Aaron T. Beck and other
colleagues, is a 21 Question multiple-choice self-report inventory that is used for
measuring the severity of children and adults.

Test Administration

The test was administered on 25-12-2022 in a well light and ventilated room in
Hospital. There was a noise in this room. The client was sitting on a chair and the
instructions were given to her. He took 20 minutes to complete the test.

Quantitative Analysis

Cut -off Obtained Range Result

Items scores scores
0-21(Mild
21 16 32 anxiety) Moderate Anxiety
22-35(moderate
anxiety)
Above to 36
(severe anxiety)
Beck anxiety inventory is used to measure the symptoms of anxiety. Beck anxiety
inventory was administered to judge the anxiety level in the client, if any client
takes 0-21 that indicted very low anxiety. 22-35 indicate moderate anxiety. And
exceed 36 above or above indicate the high anxiety. The client obtained scores is
32 which fall in moderate anxiety and according to DSM-V it’s come in moderate
anxiety disorder.

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 Personality Test

House Tree Person (HTP)

The test was administered on 31-12-2022 in well light and ventilator room of
hospital. There was a noise in this room. The client was sitting on a chair and
instructions were given to her. She took 20 minutes to complete the test.

House

Client Drawing house indicate client concern with home life and interfamilial
relationship. The client drawn picture of house consist only one room which
shows the anxiety, emotional dependence and feeling of loneliness. The lines and
wall draw strongly that represent client need for protection and anxious. Door
knobs indicate client excessive concern over interpersonal relationships. The door
closed indicates that client is introverted and self-central. Open windows show
client need for outer contact and want others talk to me. Shrubs around the house
indicate that client is insecure erect self-protective barrier. Shorter length of house
represents that client has low self-esteem.

Tree

Tree indicates client personality and his impression in relation to his environment.
Small tree indicate that client is not satisfied in his life. There is shading of roots
indicate client anxiety. Thin trunk indicates client maladjustment in environment.
Branches tiny inward indicate client introverted, self-centered and anxious. Cut-
off branches indicate client feel insecure. Multi-dimensional branches indicate
adequate control on emotions. Bark heavily shaded indicate client feel anxious.

Person

Human drawing is most obvious and conscious representation of self and

represents inner and outer behavior of person. Heavily lines pressure during
drawing reveals client tension. Client has drawn large head which show that
person is confuse about self-image. Large eyes indicate client is anxious and
oversensitive to social opinions. Pupils omitted represent client has poor coping
and communication skills. Hair’s omission indicates client has low energy level
and confuses thinking. Large trunk indicate client many unsatisfied needs and

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goals. Unequal and tiny shoulders represent client is emotionally unstable and feel
inferior to other. Arms indicate client Willingness to engage with environment.
Client pointed fingers show he is aggressive. Client thin and weak legs represent
that client feel insecure and dependent.

Diagnosis:

According to the DSM-5 and assessment results client might be with the problem
of 309.81(F43.10) post traumatic stress disorder (PTSD).

Case Formulation

Client is 35-year-old man. He belongs to nuclear family. His parents are alive. He
was first child in his family. His family faced different crises. He come to hospital
with presenting complains of low mood, severe headache, and feeling of worry,
loss of interest, sleep disturbance and restlessness. His illness started after the
death of his spouse and being alone at home. He has good relationship with his
wife. The road accident case death of his spouse. He has only one male baby that
was gone with his grandparents. The client almost 2 years before now started
drinking wine to get rid of from tensions. He feels loneliness. He thought very
much about his family. So, he was mentally disturbed. The fear of loneliness
developed. Informal assessments were done by interview, mental status
examination test and subjective rating scale. MSE was applied on him to check his
behavioral intellectual functioning at time of visit. Then BAI was used to measure
the anxiety in client. Personality assessment HTP to access the personality
functioning of client. The assessment of personality revealed that he is disturbed,
worried, and feeling of loneliness. The predisposing factor family responsibilities.
The precipitating factor for client is his loneliness after the death of his spouse.
His muscles stretched and remain worried all time. The precipitating factors of
client were home atmosphere, where he remains alone. There is also a reason of
his disorder that was his son left him alone after the death of his spouse. The
maintaining factors or the reoccurrence of the disorder was the lack of social
support and environmental factors. The most maintaining factor for client is his
worried thoughts, low mood and feeling of low energy. It is common in clinical
experience. There also anxiety and faulty beliefs which can maintain this disorder.

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(Aaron Beck, 2002), believes that negative thinking rather than underlying
conflicts lies at the heart of depression. The protective factor is his family support.

Prognosis

The client has not very social and family circle so has to take lot of time to
recover from that disorder.

Management plan

Intervention plan was designed to help the client to resolve problems he was
facing and to aid the natural process of adjustment, to develop a positive self-
concept and to save his, and to learn to interact with others.

Therapeutic Interventions

In the management plan we discussed those treatments and therapies that are most
appropriate for the treatment of a client. A therapeutic intervention is an effort
made by individuals or groups to improve the well-being of a client who either is
in need of help but refusing it or is otherwise unable to initiate or accept help.

 Psychotherapy
 Stress Inoculation Training
 Eye Movement Desensitization and Reprocessing (EMDR)
 Sleep hygiene

Treatments and Therapies

The main treatments for people with PTSD are medications, psychotherapy (“talk”
therapy), or both. Everyone is different, and PTSD affects people differently, so a
treatment that works for one person may not work for another. It is important for
anyone with PTSD to be treated by a mental health provider who is experienced
with PTSD. Some people with PTSD may need to try different treatments to find
what works for their symptoms.

Psychotherapy

Psychotherapy (sometimes called “talk therapy”) involves talking with a mental

health professional to treat a mental illness. Psychotherapy can occur one-on-one
or in a group. Talk therapy treatment for PTSD usually lasts 6 to 12 weeks, but it

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can last longer. Research shows that support from family and friends can be an
important part of recovery.

Many types of psychotherapy can help people with PTSD. Some types target the
symptoms of PTSD directly. Some other therapies focus on social, family, or job-
related problems. The doctor or therapist may combine different therapies
depending on each person’s needs.

Effective psychotherapies tend to emphasize a few key components, including

education about symptoms, teaching skills to help identify the triggers of
symptoms, and skills to manage the symptoms. One helpful form of therapy is
called cognitive behavioral therapy, or CBT.

CBT can include:

● Exposure therapy

This helps people face and control their fear. It gradually exposes them to the
trauma they experienced in a safe way. It uses imagining, writing, or visiting
the place where the event happened. The therapist uses these tools to help
people with PTSD cope with the client's feelings.

There are other types of treatment that can help as well. People with PTSD should
talk about all treatment options with a therapist. Treatment should equip
individuals with the skills to manage their symptoms and help them participate in
activities that they enjoyed before developing PTSD.

Stress Inoculation Training

SIT is a type of CBT. Clients can do it by themselves or in a group. They won't

have to go into detail about what happened. The focus is more on changing how
they deal with the stress from the event.

The client might learn massage and breathing techniques and other ways to stop
negative thoughts by relaxing your mind and body. After about 3 months, Clients
should have the skills to release the added stress from their life.

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Eye Movement Desensitization and Reprocessing

With EMDR, you might not have to tell your therapist about your experience.
Instead, you concentrate on it while you watch or listen to something they're doing
maybe moving a hand, flashing a light, or making a sound.

The goal is to be able to think about something positive while you remember your
trauma. It takes about 3 months of weekly sessions.

Sleep hygiene

In order to improve sleeping habits Jacobs illy in 2005 defined some tips Limiting
daytime naps to 30 minutes Don’t go to bed unless you are sleepy. If you are not
asleep after 20 minutes, then get out of bed. Begin rituals that help you relax each
night before bed. Get up at the same time every morning. Keep a regular
schedule. Regular times for meals, medications, chores, and other activities help
keep the inner body clock running smoothly. Don’t read, write, eat, watch TV,
talk on the phone, or play cards in bed. Do not have any caffeine after lunch. Do
not have a cigarette or any other source of nicotine before bedtime. Do not go to
bed hungry, but do not eat a big meal near bedtime either. on a regular basis, but
do it earlier in the day. Client suffered from sleep issues therefore these tips will
help her out in maintaining good sleep.

Anger management

Anger management is to help people decrease anger. It reduces the emotional and
physical arousal that anger can cause. Many different events can make someone
angry. These may include:

● Internal events such as perceived failures, injustices, or frustrations

● External events such as loss of property or privileges, teasing, or

humiliation

The goal of anger management therapy is to teach people how to examine their
triggers. It also helps people adjust how they look at situations. Successful anger
management therapy develops healthy ways for people to express anger and
frustration (Awalt, Reilly, & Shopshire, 1997). Some techniques used in anger
management therapy include: Impulse control Self-awareness Meditation
Frustration management (sometimes by writing in an anger diary) Breathing

15
techniques Relaxation strategies. As the client was suffering from anger outburst
therefore anger management is necessary. It helps her in identification of triggers
and provides her a good way of showing aggression in a meaningful and sensible
way.

Relapses Prevention

Relapse prevention is a systematic method for teaching recovering patients to

recognize and manage warning signs. PTSD symptoms can come and go over
many years. A relapse is the return of enough symptoms to meet the criteria for
diagnosis with PTSD. Though you might not have a full relapse, you may find
yourself slipping into old patterns of thought or behavior. It will be beneficial for
the client by reviewing potentially provocative thoughts and experiences which
may contribute to relapse impulses, by brainstorming solutions with the client for
problematic situations (Ellis & Dryden, 1997).

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Appendences

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2. Obsessive Compulsive Disorder

Background/ Information History

Client was apparently alright almost 2 years ago. After the COVID 19 she lost interest
in studies. She got less marks in exams. She used to have breathlessness due to stress.
After that she started to keep herself away from her friends. She started suspecting
everything and started washing her hands more often. Her friends started mocking
her. This was continued for 9 months almost. She always thought that what happened
to her if she caught the virus. Her family noticed changes in her. But initially her
family ignored these things. But after her behavior changed her parents consulted a
local doctor.

Name U.A

Age3 19 years
Gender Female
Education College Student
Weight Status 35kgs
No of siblings 4
Birth order 2nd
Religion Islam
Informant Client himself

Reason and Source of Referral

The client parents brought their daughter to Cheema Heart and Diagnostic Complex.
The client was initially checked up by the medical specialist and then after
documentation referred to Psychiatrist. She has the complaints of repetitive thoughts,
fear of germs, receptive thoughts, arrangements setting, dish washing behavior,
muscle problem. The client was refered to the psychiatrist for the purpose of
psychological assessment and management of her problem.

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Presenting Complaints of the patient

Duration Presenting complaints

1 ‫سال‬ ‫تنہائی پسند یا تنہائی میں رہنا ۔‬
1 ‫سال‬ ‫کسی کام پر توجہ مرکوز نہیں کر پانا‬
1 ‫سال‬ ‫زیادہ سوچنا‬
9‫ماہ‬ ‫ہاتھوں کو با ر بار دہونا۔‬
1 ‫سال‬ ‫ناکامی کا خوف رہنا۔‬
1 ‫سال‬ ‫سانس کا پہولنا‬

History of present illness

According to client, the client was she had been suffering from the due to rude
behavior opposed by the friend’s circles on her. She is also suffering breathlessness
due to stress. She is suffering from depression. According to the client, After the
COVID 19 she lost interest in studies. She got less marks in exams. She used to have
breathlessness due to stress. After that she started to keep herself away from her
friends. She started suspecting everything and started washing her hands more often.
Her friends started mocking her. This was continued for 9 months almost. She always
thought that what happened to her if she caught the virus. Her family noticed changes
in her. But initially her family ignored these things. But after her behavior change her
parents consult the doctor. She started to remain depressed most of the time. She feels
headache due to depression with repetitive thoughts. She remains stressed and don’t
want to do any work.

Personal History:

Her birth was normal. No history of any infection or exposure to radiations during
pregnancy. Her mother has no habit of drug abuse. Client was born with normal
delivery without any complications. According to her mother she was given all the
vaccines. According to her mother she developed all his milestones without any
complications.

Early childhood

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Patient reported that her early childhood was not satisfactory she was an ignored
child. Her parents did not love him. Her parents did not pay attention to her.
According to patient, she had only few friends but she was not emotionally attached
to them.

She was close to his mother. She had a fear of losing her mother during childhood.
She was a sensitive in childhood and she did not enjoy her childhood so much.

Schooling

She reported that she started her school at the age of 5. She was an average child. She
was shy. She did not respond to teacher's queries. She was not friendly in nature.

Educational History

She took admission in allied college in the age of 18 years. She was average student
with average marks. She was happy at that time period. The client reported that she
was an average student. The client was also participated in extracurricular activities.
She had good relationships with her teacher and fellows. According to the client she
had friendly relations with all her class fellows and used to play with them.

Adolescence:

Client reported that she did not feel good when her hair growth started and become
shy in this period in classroom.

Family history

The client belonged to a middle socioeconomic status. They live in a nuclear family
system. Patient’s mother age was 35. She reported that her mother was submissive
and typical housewife. The bonding between her parents is satisfactory. They don’t
have conflicts between them. She also mentioned her relationship with her father in
which she said he gave her independence and she shares a good relationship with her
father from the past 10 months. According to client their parents had arranged
marriage. Now they are happily married there are no conflicts between them they
have a lot of understanding between them which is very good for their home
environment and also for her. Client has 4 siblings.

Family History

Her parents didn’t have any illness or disease.

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Family monthly income:

Client reported that their family income is Rs. 80,000/-.

General Home Atmosphere:

Client reported that they lived in a nuclear family. There were 5 rooms everyone lived
in their own room. She didn’t share her room with anyone. According to patient they
lived in their own house.

Social History

The client was introverted in nature. The client reported that she did not having many
friends. She didn't have a big social circle of friends. She was not very active and
sociable. She isolated herself and also experiences loneliness from the past 5 months.
But now she had social phobia.

Premorbid (Before Issues) Personality

The client was spending happy life before this incident. She has good relationship
with her siblings as well with parents. She has limited friends circle. She is not so
social. She is having introvert behavior. She was close to her mother. She spent her
leisure time in watching television. She was very conscious about her health.

Expression of emotions

According to patient, she was not expressive in nature but sometimes she cried when
she faced something stressful.

Problem solving and decision making

Client reported that she did not have adequate problem-solving skills and she faced
trouble while making decisions.

Self-image

She thinks that people made fun of her, due to her habits.

Self-concept

She reported that she was disciplined and well-mannered but sensitive and easily
irritated. She was highly creative and gave attention toward details.

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Response to stress:

She reported that she isolated herself and got panicked. According to her, she kept
thinking about it; until resolved. She cried when she faced stressful situations.

Life goals:

she reported that she wanted to become a successful woman in life.

Attitude toward religion:

According to client she was not religious. She didn’t perform daily prayers. She
reported that she had a week relation with God.

Medical and Psychiatric History in Family

The client family had no medical history of any psychological disorder.

Psychological Assessment

Psychological assessment was done on both formal & informal level using the
following measures:

Informal Assessment

Informal assessment is a non-Standardized procedure for obtaining information that

can be used to make judgments about a client's problematic behavior and
characteristics (Cowen, 2006).

Clinical Interview

The clinical interview was the most fundamental component of counselling,

psychiatry and psychology and was a basic unit of connection between the helper and
the person seeking help. It was the beginning of a therapeutic relationship and the
cornerstone of psychological assessment (Jones, 2010; Sommers-Flanagan, 2016).

One of the main roles of a psychologist was to conduct clinical assessments to

determine whether a client was suffering from a psychological or behavioral disorder.
During the clinical interview, a psychologist would gather information regarding a
client's family history, social life, employment, financial situation, previous
experience in mental health treatment and other factors that could impact on mental
health and well-being. The interview was helpful in eliciting information that was
later helpful in making a conceptualization of his case for better treatment. This type

26
of interview was carried out in the first 3 sessions and formal assessment also was
carried out. Question was asked for the diagnostic purpose and an informal
assessment was completed in this manner. By the clinical interview, detailed
information was gathered regarding illness.

Mental State Examination:

She was wearing a neat and clean dress of seasonal appropriateness. Her hair was
combed well. The color of her hair was brownish and the texture was a little good.
Her hygienic condition was also fine. She was overall dressed well. During the
interview, initially she was seated uncomfortably. The client was not maintaining eye
contact when she was asked about her family relations at first later attitude on during
interview was cooperative.

At the start of the session, her expressions indicated that she was nervous and she was
not comfortable. By the time, she got comfortable and her tone was satisfactory.
Sometimes she was not logical in her thoughts. The orientation of the patient was
good she knows the place, time and the person. The patient was attentive and
concentrated during session. The memory of the patient was not affected. She
remembers the short-term memory.

Formal Assessment

It is a type of clinical assessment in which the doctor uses standardized tests in a

structured to assess the patient. For example, a questionnaire with multiple questions
and possible answers (optional) is created and used to interview the patient.

Obsessive Compulsive Disorder Inventory

This scale is used to check the severity and obsesses level of stress in the patients.
This scale is invented by Wayne Goodman and his colleagues. This is divided into
symptoms checklist and severity scale.

Test Administration

The test was administered on 01-01-2023 in a well light and ventilated room in
Hospital. There was a noise in this room. The client was sitting on a chair and the
instructions were given to her. He took 20 minutes to complete the test.

27
Behavior Administration

The client was 19 years old. He looked nervous during the test. She treats to take the
test with concentration. Rapport was established and maintained.

Quantitative Analysis (YBOCS)

Table is showing the items, cut-off score, obtained score and category of disorder.

Items Cut off Obtained Range, Category Result

Scores Scores
01-14, Mild Moderate
YBOCS 40 25 15-23, Moderate to Severe
20-28, Severe OCD
30-40, Disabling
Total scores on the measure range from 0 to 40, with a score of 0–7 indicating
subclinical symptoms, 8–15 mild symptoms, 16–23 moderate symptoms, 24–31
severe symptoms and 32–40 extreme symptoms. The scale can also provide a
subscale score for obsessions and compulsions (range 0–20) separately. In this case
the score is 25 which means the client has moderate to sever to moderate OCD level.

Behavioral observation:

Client came into office with her mother. She was well dressed and perfectly combed
her hair. Before sitting on chair, she cleaned the chair. She placed her cell phone on
table symmetrically. While talking, she was constantly taping her fingers on the side
of chair. Her tone was satisfactory. She was not maintaining eye contact.

Personality Test

House Tree Person (HTP)

The test is administered on 05-1-2023 in well light and ventilator room of hospital.
There is a noise in this room. The client was sitting on a chair and instructions were
given to her 28 minutes to complete the test.

House

House is at bottom of edge showing client is insecure and inadequate depression. She
is shy so she avoids from interpersonal relationship. Missing chimney represents
client lose psychology warmth to home. Very small and closed door indicate she has

28
withdrawal behavior and tend to back off from others. Shrubs around house has
insecure and erase self-protective. Absence of pathway reveals that she did not want
anyone or may be not anyone involve in her personal life. The presence of the car
shows the concern of her future plans and curiosity.

Tree

Tree reflect deeper and unconscious feelings about herself. Broad based trunk indicate
client inhibit and slow comprehend. Client has feeling powerlessness and depressive
tendencies. Scars on trunk represent traumatic experience. The presence of sparrow
on tree shows her concern and care for the pets or birds.

Person

Client draw large head indicates client is self-centered, poor emotionally. Hairs
showing client is aggressive, quilt feelings, overly sensitive to criticism and sexually
preoccupation. The client has drawn large orbits of eyes with tiny pupil which reveals
that she has guilty feeling nose indicates client has depressive tendencies and
unwanted thoughts. Mouth represents client depressed and has eating disorder. Client
small arms showing lack of confidence, feel insecure and antisocial behavior. She has
excessive security needs and poor control of impulses.

Diagnosis:

Client was diagnosed with obsessive compulsive disorder (OCD). On the basis of
symptoms, patient was diagnosed with OCD 300.3 (F42).

Prognosis

Her prognosis was good and she had better chances of recovery. She had a social
support siblings and parents supports very well.

Case Formulation

The client is Nineteen years old and she belongs to a middle class family. She came
with the presenting complaints. The prodromal manifestation was the lack of interest
into her studies. The precipitating factor was the belief of failure in future exams.
The predisposing factors were the availability of friends’ circle who are compelling
towards this attitude. Protective factors were the family support (parents and sister).
According to DSM-5 the client is diagnosed Obsessive Compulsive Disorder 300.3
(F42. Different techniques including Cognitive Behavior Therapy, Psychotherapy,

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Exposure and Response prevention therapy and relaxation Techniques will be used.
Case formulation by psycho social model. The treatment and management plan is
done in therapeutic treatment as rapport building by assuring the privacy and
confidentiality of the client.

Treatments and Therapies

 CBT cognitive behavioral therapy

 Psychotherapy
 Exposure and response prevention therapy
 Exercises

Cognitive behavioral therapy (CBT):

Cognitive behavioral therapy (CBT) is a talking therapy that can help you manage
your problems by changing the way you think and behave. It's most commonly used
to treat anxiety and depression, but can be useful for other mental and physical health
problems.

How CBT works

CBT is based on the concept that your thoughts, feelings, physical sensations and
actions are interconnected, and that negative thoughts and feelings can trap you in a
vicious cycle. CBT aims to help you deal with overwhelming problems in a more
positive way by breaking them down into smaller parts. You're shown how to change
these negative patterns to improve the way you feel. Unlike some other talking
treatments, CBT deals with your current problems, rather than focusing on issues
from your past. It looks for practical ways to improve your state of mind on a daily
basis.

CBT sessions

If CBT is recommended, you'll usually have a session with a therapist once a week or
once every 2 weeks. The course of treatment usually lasts for between 5 and 20
sessions, with each session lasting 30 to 60 minutes. During the sessions, you'll work
with your therapist to break down your problems into their separate parts, such as
your thoughts, physical feelings and actions.

You and your therapist will analyze these areas to work out if they're unrealistic or
unhelpful, and to determine the effect they have on each other and on you. Your

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therapist will then be able to help you work out how to change unhelpful thoughts and
behaviors. After working out what you can change, your therapist will ask you to
practice these changes in your daily life and you'll discuss how you got on during the
next session. The eventual aim of therapy is to teach you to apply the skills you have
learnt during treatment to your daily life. This should help you manage your problems
and stop them having a negative impact on your life, even after your course of
treatment finishes.

Psychotherapy:

Psychotherapy is the use of psychological methods, particularly when based on

regular personal interaction, to help a person change behavior, increase happiness, and
overcome problems. Psychotherapy, or talk therapy, is a way to help people with a
broad variety of mental illnesses and emotional difficulties. Psychotherapy can help
eliminate or control troubling symptoms so a person can function better and can
increase well-being and healing. Problems helped by psychotherapy include
difficulties in coping with daily life; the impact of trauma, medical illness or loss, like
the death of a loved one; and specific mental disorders, like depression or anxiety.
There are several different types of psychotherapy and some types may work better
with certain problems or issues. Psychotherapy may be used in combination with
medication or other therapies.

Therapy Sessions

Therapy may be conducted in an individual, family, couple, or group setting, and can
help both children and adults. Sessions are typically held once a week for about 30 to
50. Both patient and therapist need to be actively involved in psychotherapy. The trust
and relationship between a person and his/her therapist is essential to working
together effectively and benefiting from psychotherapy.

Psychotherapy can be short-term (a few sessions), dealing with immediate issues, or

long-term (months or years), dealing with longstanding and complex issues. The goals
of treatment and arrangements for how often and how long to meet are planned jointly
by the patient and therapist.

Confidentiality is a basic requirement of psychotherapy. Although patients share

personal feelings and thoughts, intimate physical contact with a therapist is never
appropriate, acceptable or useful.

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Main goal of psychotherapy

In summary, the goal of psychotherapy is to facilitate positive change in clients

seeking better emotional and social functioning to improve their feelings of
satisfaction and the overall quality of their lives.

Exposure and Response Prevention (ERP) Therapy:

Exposure and response prevention (ERP) therapy is one of the most effective forms of
treatment for OCD. ERP therapy is a behavioral therapy that gradually exposes people
to situations designed to provoke a person's obsessions in a safe environment. A
hallmark of ERP is that is doesn't completely remove distressing situations and
thoughts. ERP therapy can gradually reduce their anxieties and stop the problematic
cycle of OCD.

A hallmark of ERP is that is doesn’t completely remove distressing situations and

thoughts. Not only can distress not be eliminated from someone’s life altogether but
doing so would make it impossible for patients to cope during everyday situations.

ERP provides a patient with coping skills for when a triggering situation presents
itself, allowing them to then use the skills to prevent their compulsion from taking
over.

When getting started with ERP, obsessions will remain a challenge in the short term,
but they will no longer seem overwhelming. By further developing coping skills, ERP
can free people from the cycle of obsession and compulsion.

How ERP Works

To understand how ERP works, consider its use for a well-known obsession of OCD:
a fear of contamination in most cases, germs.

People whose OCD stems from a fear of germs may continuously wash their hands to
the point at which their skin turns raw. The compulsion can make them chronically
late for activities. Anyone with these symptoms could potentially benefit from ERP
therapy. For someone who is afraid of catching germs from a doorknob, for example,

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the way to overcome this fear using ERP would be for them to touch the doorknob. A
clinician may then have the individual touch their face and their wallet to address the
fear of spreading germs.

An important step in ERP would include the patient stopping themselves from
engaging in the ritual of hand-washing. This last part prevents the patient from
reinforcing the obsession through avoidance. All of these steps help the patient
tolerate both the discomfort of having germs on their hand and the uncertainty around
what might happen next.

This can seem like a big, frightening change for someone with a fear of
contamination. Because of this, therapists usually start with low to moderately
anxiety-provoking exposures and work their way up to higher-level exposures.

How effective is exposure and response prevention?

ERP is extremely effective at treating OCD, with a success rate of 65% to 80% in
children, adolescents, and adults. While everyone responds to therapy differently,
most see a decrease in OCD symptoms within anywhere from eight to 16 weeks;
some even find their symptoms disappear altogether.

Exercises:

Exercising on a running wheel helps them sprout new connections between neurons in
their brains. Exercise may cause the release of “growth factors,” which trigger
neurons to make new connections. These new connections may help to reduce
symptoms of OCD.

Exercise get rid of OCD

Scientists have found that exercise, when used as part of a comprehensive treatment
plan, can support faster and more lasting recovery from OCD. One study, led by Dr.
Ana Abrantes of Butler Hospital in Rhode Island, showed that adding exercise to an
OCD treatment regimen can lead to better results.

Walk

Just 5 or 10 minutes of movement could potentially improve your mood and other
OCD symptoms, she suggests, based on research for other mental health conditions.
So if your mood dips or compulsive thoughts are bubbling, lace up your sneakers and
take a little walk or brisk run, or move in any way you enjoy.

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Deep breathing

The relaxation that comes with deep breathing will kick in after a minute or two, but
keep going for five, 10 or even 20 minutes for maximum benefits. During belly
breathing, we experience a reduced heart rate, lowered blood pressure and more
efficient breathing, each of which promotes a state of calm and relaxation.

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Appendences

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