Case Report # 2
Major Depressive Disorder
Summary of the Case
The client S.U, 22 year old male was referred with the presenting complaints of low and depressed mood, tension, hopelessness, worthlessness, lack of interest in daily activities, death wish and suicidal thoughts. Psychological assessment, comprising of clinical interview, behavioral observation, MSE, and symptom rating, Hamilton anxiety rating scale, and the Hamilton rating scale for depression was done. The psychological assessment of the client showed that he has symptoms of depression and anxiety and it was causing impairments in his everyday functioning and a diagnosis of Major Depressive Disorder was made. A management plan comprising of psycho-education, deep breathing, activity scheduling, anger management, 16 muscle progressive exercise, social skills training, coping statements, sleep hygiene, relaxation exercises and physical exercise was made for the client. The total number of sessions conducted with the client was 9 .The rate of change in the client according to his subjective ratings of the symptoms was found to be 32%.
Identifying Data
Name S.U
Age 22 Years
Gender Male
Siblings: 4 (One sister and three brothers)
Birth order: 4th
Date of referral 18.04.2016
No. of sessions 9
Reason for Contacting Psychiatric Services
The client was referred for the purpose of psychological assessment and management.
Presenting Complaints
Table.1
Presenting Complaints of the Client as Reported by the Client himself
Duration
Presenting Complaints
5 years
Depressed mood
5 years
Worthlessness and hopelessness
4 years
Lack of interest in daily activities
3 years
anxiety
5 years
Suicidal thoughts
5 years
insomnia
Initial Observation
The patient was a young man having average height and body structure and wheatish complexion. He was dressed in shalwar kameez that wasn't properly pressed. He was looking down towards the floor while talking. He was giving inadequate eye contact. He was talking in low tone. His eyes were swelled and little red just like he cried a lot.
History of Treatment and Present Illness
The patient had few anxious traits and had negative view about the world, but he somehow managed the minor problems of his life. According to the patient, his life had changed dramatically after two main incidents happened in his life. In 2007, the patient got kidnapped by the Talibaans from his home. The patient described the Talibaans as “hungry wild dogs” as they tortured him a lot. At that time the patient was in school and once in his school he expressed his intense desire to join PAK Army so that he could fight with the enemies to save his country. He reported that somehow the Talibaans came to know about him and they thought that he was an agent of Army or any Intelligence agency so they kidnapped him from his home. They had beaten him badly and he was about to die. He was under their control for two weeks. When the Talibaans got confirmed that he wasn't any agent of Army or intelligence agency and also he and his family had no associations with armed forces, they let him free. He got freedom on the condition that he will never let the forces know about this incident and areas of Talibaans, otherwise he will be killed. He was also informed that he and his family will be observed by them and they had to face severe consequences if they reported to police or Army about this. After this incident the patient's desire to join Army was enhance and he wanted to take revenge from Talibaans. After his intermediate, he asked his family to let him join the Army but they didn't allow him. He applied in Army as a soldier without the knowledge of his family and he got letter to ISSB for final selection process and at that time he told his family about his intentions but his father told him that he cannot go for ISSB otherwise he will no more be a member of their family. He had an argument with his father that I had faced the brutal face of Talibaans and I want to wipe them out of our country. He reported that his family didn't allow him because they had faced the “inhumane Swat Operation” and they were scared of the incident happened before. He reported that he weeped a lot to convince his family but they didn't agree. He reported that his family's behavior broke him into pieces. It was more hurting than being kidnapped by the Talibaans. The patient was admitted to the university against his will in 2011. The second important incident happened to the patient was a breakup with his female friend who was his class fellow. He reported that after being friends with her, he started to live a normal life and somewhat recovered from the past mishaps. The life seemed beautiful and worth living to him. But all of sudden she broke up with him and she even didn't tell the reason. According to the patient, he tried hard to fix his relationship but the girl stopped replying him and he was broken again. His relationship lasted about 4 months. He left the university. He was depressed and suicidal ideation was on the peak. He tried twice to end his life and several minor injuries to self. He tried to cut his jugular vein to commit suicide but got rescued by his elder brother. He was moved to a hospital in Peshawar for early treatment. He remained their for 3 weeks. He also got medication from psychiatrist in Peshawar. After some time he again tried to commit suicide by taking poison. At that time he was moved to a hospital in Rawal Pindi. He also got 5 ECT sessions there. After taking ECT he never tried to commit suicide rather he started to pray for his death. He also experienced anxiety when going to university and watching uncertain, doubtful love stories in dramas or movies, fear in darkness, sometimes he have elevated mood but his mood gets decline after sunset, lost interest in academics, worthlessness, death wish.
Background Information
Personal History
As reported by the client he was born by normal delivery and no pre and post natal complications were reported. The first cry of the patient was timely. He was a healthy and active infant with no significant delay in milestones. He was a hard working student. He never had difficulty in adjusting in new situations and with new people. The patient had nightmares, he also get scared if someone calls him in loud voice while he was sleeping and sometimes he screams out of fear. He also felt fearful when alone and in darkness. He also gets anxious while watching dramas and movies having a romantic scene and suspense. He reported that he had only one wish since his childhood and that was to join PAK Army and he doesn't like to study anything else. He reported that he is studying because he needs to get educated for his bread and butter, to be able to earn not merely because he likes to study.
Educational History
The patient reported that he started his school at the age of 5 years and at the same time he was also admitted to religious school to learn the Holy Quran by heart. He reported that he didn't face any difficulty in adjusting in school, he was happy to go to the school but he didn't like to go to Madrassa because it was difficult for him to memorize the Quran. He had no truancy history from the school but he kept on changing the Madrassa. He was scolded and beaten several times by his father and religious teachers for not learning the Quran but he was still reluctant to go there. He had to go to religious school up to 10th grade but he had hardly memorized 5 Para of the Quran. He had friendly relationship with his class fellows and teachers. He also never had adjustment problems in the college. Although the college had strict rules and regulations but he never missed the college unnecessarily. He reported that he had glorious time in his academic life till 2011, when he got admission to the university. He reported that he spent his first day at university by having fun with his class fellows and was happy. But he left the university in first semester due to failure in love affair. He took admission in another university in 2012. In the second university, he have distant relationship with his class fellows and teachers. He felt anxious when going to university. He reported that he remained a topper of his class till 2011 but after that his study had effected from depression. He had lost interest in studying and became average student of his class securing 14th rank out of 36 students.
Family History
Father: The father of the patient is 59 years old. He is a teacher by profession. The patient reported that his father is quite strict with him. He does not have a stable mood. He gets angry on little things and sometimes he doesn't bother big mistakes of his children. The patient does not share anything with his father. He had a distant relationship with his father. His father is a patient of high blood pressure. The patient also reported that his father was against his desire to join PAK Army. His father used to called him a coward and dumb. He had an argument with his father in this regard. He also reported that his father scolds him on little things just like watching T.V., using facebook and cellphone, reading novels, wearing black clothes, listening to songs, buying new clothes without permission, spending money on junk food because his father believes that these things will spoil his repute in society. His father also does not bother much if the patient is having any physical illness.
Mother: The mother of patient is 50 years old. She is educated up-to matric. She is a house wife. The patient reported her mother as friendly and caring person. But he also have a distant relationship with his mother. He doesn't share anything with his mother. She is a patient of diabetes and high blood pressure. The patient reported that his mother supported him to join Army but she couldn't make his father agree to let the patient join Army.
Sister: The patient has only one sister. She is eldest among siblings. She was 30 years old and married. She is a house wife. She got married in her early adolescence, when the patient was in grade 1. He didn't receive her sister's love and affection due to her early marriage. The patient reported her sister as short tempered and aggressive lady. His sister used to snub him on little things. She scold him on wasting his time and not paying attention to his studies. She was also against his desire to join Army.
Brother: The patient's eldest bother is 28 years old. He is lecturer in a college and he is married. The patient described his brother as friendly, affectionate and caring person. He has somewhat close relationship with his brother. He used to share his problems with his brother and his brother used to help him in all possible ways.
Brother: He is 26 years old and he is a lecturer in a college. He is engaged. The patient has distant relationship with his brother. He reported that he is suspicious about his brother that he might evoke his father to scold the patient on little things. Further he reported that he doesn't like his brother because he used to point him out on little things and he thought that his brother is jealous of him.
Brother: The youngest brother is 18 years old. He is a student of intermediate. The patient has close relationship with his brother. He is frank and sharing with his youngest brother. He also has a shared room with his brother
The patient: The patient belonged to a middle class family of Swat, Pakistan. He lived in a nuclear family. He reported that overall environment of house was somewhat good. All the siblings have a distant relationship with father because of his strict nature. Although he has close relationships with his mother and brothers but he couldn't share his inner feelings and problems with them. Also he never had any close friend with whom he can share his inner feelings.
Occupational History
He was teaching in a college to keep himself busy and was satisfied with his job and salary. He didn't have frankness with his colleagues because they are much elder than him. As reported by the patient, his students felt relaxed and at ease with him.
History of substance abuse
The client did not report any kind of drug usage.
Sexual History
The patient reported that he reached puberty at the age of 15 years and his reaction toward puberty was normal as he had seen his elder brothers passing through this stage. He reported that he didn't felt attraction towards girls. But when he got admission to the university (in 2011) he felt attracted to his class fellow. The girl also liked him and she offered him to be friends with her. At first he resisted to her friendship due to strict rules of the society but he found himself unable to control his feelings for her and he fell in love with her. They used to talk on the cellphone but they never met other than in class. He reported that they never talked about sexual matters. After four months the girl broke up with him without any obvious reason and he felt depressed after that incident. After 2 years of this incident he proposed his class fellow to distract himself from his first affair but she refused his proposal which added further sadness and worthlessness in patient. The patient didn't report any masturbation habit.
Religious Inclination:
The patient reported average inclination towards religion as he didn't like to learn Quran and he didn't offer his prayers regularly. But he offers Jumma prayer and Eid prayers on regular basis.
Premorbid Personality
The patient reported that he is kind and caring person. He used to help other people regardless of their caste, creed and color. He found himself unable to say no to any one. He wished that everyone lived a problem free life. He tried to keep everyone happy with his jokes and liked to make other laugh. But he believed that people are selfish and they don't bother about my caring nature. They are in the world to create disturbances in other's lives. He believed that generally people are terrible, fake and non-reliable, they appear to be very decent but they play with feelings and hurt others. He had patriotic intentions towards his homeland. He wanted to be an Army officer to save his country from enemies. He liked to use facebook, read poetry, novels and military related book, and listening to music in his spare time. He reported that he liked to be friends with everyone. According to him, he gets angry easily but he had never indulged in physical fight. He argues and then leave the situation and later on he share his feelings with brother. Besides of his father's aggressiveness, he never showed disrespect to him. He was fond of riding and had won many races, but since 2011 he had lost interest in his pleasurable activities. He reported that he got hurt easily whenever anyone points out a little bad in him.
Psychological Assessment
Psychological assessment of the client was carried out on two levels including Informal and Formal assessment.
Clinical Interview
A clinical interview was conducted with the client to get detailed history of all kinds for the purpose of understanding the case thoroughly. During the clinical interview the client was cooperative and willing to provide all the required information.
Subjective Ratings of Client’s Problematic Symptoms
Subjective ratings of the client’s problematic symptoms were taken by the therapist, on a 0-10 scale to assess their preset severity level, which are shown in the table below.
Table.2
Table Showing Subjective Ratings of the Client’s Symptoms on 1-10 Scale
Symptoms
Client’s ratings
Depressed mood
10
Worthlessness
10
Suicidal thoughts
10
Anxiety
9
Lack of interest in daily activities
8
hopelessness
10
Insomnia
10
Mental Status Exam
Mental Status Exam was done to assess the current mental state of the client. His short and long term memory was intact. His attention and concentration was also intact. He was well oriented in time, place and person. He had well insight about his problem as he knew that his problem is not physical but psychological, and he admitted that he is depressed and needs treatment. He did not have hallucinations or delusions.
Hamilton Anxiety Rating Scale (HAM-A)
Hamilton Anxiety Rating Scale (HAM-A) was administered on the client. The client scored 31 on the scale which describes severe anxiety.
Hamilton Rating Scale For Depression
Hamilton rating scale for depression was administered on the client. He scored 29 on the scale which depicts very severe depression.
Diagnosis
Keeping in view, the diagnostic criteria of DSM 5, the client was diagnosed with Major Depressive Disorder 296.32 (F33.1) with moderate anxious distress.
Prognosis
The client was diagnosed with a chronically relapsing yet treatable condition. His condition can be managed to ensure that he does not encounter a relapse. If proper support is provided to the client he can completely rid himself of his depressive symptoms. The supporting factors in this case were the client's willingness to overcome his symptoms and his motivation. But the negative factors such as lack of family's support can hinder his treatment.
Case Formulation
The client S.U was referred with the symptoms of low and depressed mood, tension, hopelessness, worthlessness, lack of interest in daily activities, death wish and suicidal thoughts. Formal and informal assessment was done on the client and in the light of the conducted assessment case formulation of the client was done.
The symptoms of the client developed were firstly developed when he got kidnapped by the Talibaans. Later on he broke up with a girl which stimulated his symptoms and this could be the precipitating factor in his problem. Before this the client had benign symptoms and he was functioning well.
The maintaining factor in this case is the careless attitude of client’s father toward him, lack of psychological treatment due to inaccessibility, and changing the psychiatrist again and again.
The resilience factor is the client’s own willingness and effort to work towards the solution of his problem. This is very helpful in the intervention as the client is giving his own input which is very much important to help resolve and deal with the symptoms.
A management plan basically comprising of relaxation techniques, activity scheduling and coping statements was formulated for the client in order to help him deal with his symptoms. It consisted of the short term and long term goals which will be implemented on the client.
Summary of Case Formulation
Figure.1: Showing Pictorial Summary of Case Formulation
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Management
Following strategies were used with the client as an intervention plan and was implemented on him to help him resolve his symptoms.
Summary of Therapeutic Intervention
Rapport Building
Rapport building can be seen as the improvement of trust, comprehension, and regard between two persons. Rapport is a condition of nonthreatening comprehension with another individual or gathering that empowers more prominent and less demanding correspondence.
Deep Breathing
Deep breathing is marked by enlargement of the abdominal cavity rather than the chest when breathing. It enacts the parasympathetic sensory system, advancing relaxation. It is a form of complementary and alternative treatment, and is an incredible first-line relieving or establishing strategy. Deep breathing was taught to the client to manage stress and become relax.
Psycho-education
Psycho-education is a general term for an educational approach of guidance to offer accurate knowledge and information about the nature and methods of treatment and addressing the disease needed for cure added with consideration for psychotherapy. Psycho-education was given to the client in which he was provided with the information about depression and his treatment plan.
Activity Scheduling
Activity Scheduling is one of the simplest behavioral interventions in the CBT approach to depression. Depressed people tend to withdraw from 'everyday' life, and this passivity is a safety behavior which itself lowers energy levels, reduces motivation and confirms in the depressed person the view that they're best left to their own devices and ought not to bother with others.
Progressive Relaxation Exercise
Progressive relaxation therapy, is a type of therapy that focuses on tightening and relaxing specific muscle groups in sequence. By concentrating on specific areas and tensing and then relaxing them, one can become more aware of one's body and physical sensations.
Coping statements
Coping statements are truthful positive statements used to replace the negative and untrue thoughts that take-over when you feel anxious, stressed, angry and/or when facing other overwhelming situations. Some coping statements were taught to the client to replace his negative thoughts.
Sleep hygiene
Sleep hygiene means habits that helps an individual have a good night’s sleep. Common sleeping problems (such as insomnia) are often caused by bad habits reinforced over years or even decades. One can improve one's sleep quality by devising a a couple of minor alterations to lifestyle and attitude such as obeying one's body clock, improving the sleeping environment, and avoid drugs.
Physical Exercise
Physical activity stimulates various brain chemicals that may make an individual feeling happier and more relaxed. It may also make people feel better about their appearance when they exercise regularly, which can boost their confidence and improve their self-esteem.
Outcome
Subjective ratings were taken from the client to assess the post management change in the symptoms of the client.
Table.4
Table Showing the Post Management Subjective Ratings of the Client’s symptoms
Symptoms
Client’s ratings
Depressed mood
7
Worthlessness
7
Suicidal thoughts
6
Anxiety
6
Lack of interest in daily activities
6
hopelessness
6
Insomnia
8
A comparison of the pre and post ratings of the client’s subjective ratings was done to see the difference in the client’s symptoms.
The pre-management ratings of the client’s symptoms were 100% and post management ratings were 68%. The rate of change in the client’s symptoms is 32 % according to the subjective ratings of the client.
Limitations
The client was an OPD patient so he could not come more than once a week and sometimes he would even miss that one week appointment.
He started missing sessions after minor change in his symptoms.
Suggestions
The client should try to take his family in confidence and help him with his problem.
The client should not change his psychiatrist and psychologist again and again.
Session Reports
Session No: 5
Goal of Session: Anger Management
Activity conducted:
Anger Management of the client was conducted in the session. The early signs of anger were explained to the client. The client was asked to identify the symptoms he faced when he experiences anger. Then he was provided with list of techniques to prevent from anger.
Feedback:
The client identified his early signs of anger and learnt techniques to control his anger.
Observation:
The client was willing to overcome his anger. He asked questions regarding how to practice the technique which was unclear to him.
Session No: 6
Goal of Session: Deep Breathing Exercise
Activity conducted:
Deep breathing exercise was conducted with the client in the session. The client was provided with a comfortable chair and environment and deep breathing was practiced.
Feedback:
The client became relaxed after practicing deep breathing. He followed the exercise daily.
Observation:
The client was following instructions with interestingness.
Session No: 7
Goal of Session: Coping Statements
Activity conducted:
Coping statements were developed with the help of client, according to his thoughts in troublesome situations. Then he was asked to remove his unwanted thoughts with these coping statements whenever he feels distress.
Feedback:
The client had learnt the coping statements and also kept a page with him on which coping statements were written. He used to repeat these statements again and again. The client found these statements helpful in difficult situations.
Observation:
The client was rigorously learning the coping statements.
Session No: 8
Goal of Session: Activity Schedule
Activity conducted:
Activity schedule was given to the client in order to be functional in his academic, professional and social tasks.
Feedback:
The client reported that he activity schedule helped him in order to be functional and to get rid of his suicidal thoughts.
Observation:
The client was not following the given schedule in early days, but latter on he started to follow the schedule.
Session No: 9
Goal of Session: Sleep Hygiene
Activity conducted:
Sleep hygiene tips were given to the client to improve his symptom of insomnia.
Feedback:
The client reported that he his sleep routine was mildly improved by following these tips.
Observation:
The client's overall health was seems to be improved. His swelled eyes and dark circles around his eyes were improved.