A case study pattern with example

 A CASE STUDY

 

BIO DATA:

Clients Name:                x.y.z
Age:                                32 year
Gender:                          Female
Marital Status:                Married
Occupation:                  Housewife
Siblings:                        5
Birth Order:                   5th
Source Of Referral:      client herself

Presenting Complaints

Symptoms

·    Depressed mood
·    Loss of interest or pleasure in activities you used to enjoy
·    Feelings of guilt, hopelessness and worthlessness
·    Suicidal thoughts or recurrent thoughts of death
·    Sleep disturbance (sleeping more or sleeping less)
·    Appetite and weight changes
·    Difficulty concentrating
·    Lack of energy and fatigue

History of present illness

My client is 32 years old. Her education is B.A. She is married woman and facing problems in her married life. My client belongs to middle upper class family. She married to her cousin at the age of 20.Her husband is business man. She is living with her husband and one sister in law 30 years old not yet get married. When she married her husband said her I will fulfill you’re any kind of need but you have to take care of mother who was a psychotic patient. She agreed with her husband because her mother in law was her aunt.  She took great care of her. In that period of time they did not have any sexual relationship. Her husband was not capable of that. After sometime he told her that he is not capable but he convince her not to tell any one I will do my treatment. She did not tell any one because he was her cousin and she loved him. During in that time, her mother asked for many time about her pregnancy. But she always replied that every thing is fine its only God’s will that I am not having pregnancy.
After the six year of her marriage her mother in law died. When every one forced her to have her proper check up then she told her mother that her husband did not have any sexual relationship with her because he in not capable of that. Her parents forced her to leave him but she denied and told she is happy with her husband. According to my client she is satisfied with her marital life.
Now after 12 years of her marriage she has seen sudden changes in her husband’s behavior in recent one year. Now her husband don’t talk to her normally if he need some thing he calls her sister not her wife. He doesn’t give proper attention to her. Now her husband wants to do second marriage and for this purpose he is getting treatment. Because   due to some medical problem she had to operate her uterus and now she can’t conceive a baby. To gain the attention of her husband again she went to the “PEERS” without informing her husband.    Her husband was informed by his sister that his wife is trying to have control on him and for this purpose she used to go to the peers in the absence of him. Most of the time she feels sad and depressed and becoming isolated.

Family History:

The parents of my clients are died. And she is the second last among 5 sibligs.The relationship with her siblings are very good. As my client is second last and only sister of her brothers that’s why all brothers love her lot. As my client is married and in her in laws family she is living with her husband and one sister in law. Her sister in law and her husband are only two children of their parents. Her sis in law did not get marry. And she doesn’t want to get marry. The relationship of my client with her sister was normal but when she had to remove her uterus she feels that she is not suitable for my brother. She forced her brother to marry again. The relationship of my clients to her husband was good .she was quite satisfied to her husband. she never blamed to her for any kind of deed. She always served her whole life like a maid in their house. She always fulfills their any kind of need without they had to ask to her.

Personal History:

The birth of my client was normal. She achieved her all millstones development .The relationship of my client to her parents were very friendly because she was the only girl child of her parents. Her parents were very loving to her. They always care about her. She belongs to an upper middle class family. Her relationship with her siblings was very good. My client belongs to a nuclear family. The home environment of my client is very good. According to my client in her family all of my siblings are educated and they respect each other. My client was good in her studies. She have done graduate. In social relation my client was poor because just for this she permitted to go out of the home. The client did not have any kind of occupational history. According to my client the marital history of my client was quite satisfied before the operation of her uterus .The life was going good. But due to some medical problem I had to operate my uterus. And I have seen sudden changes in my husband hat he said I want baby and I want to marry again and my sister in law often force him to do marry. I m feeling day by day worthless.
Client’s mother was the patient of diabetes and also father. One of the client’s brothers was suffering from heart disease. My client’s mother in law was a psychotic patient.

ASSESSMENT

Behavioral Observation  (Informal)

A lady of age 32 came to the clinic.She was neatly dressed. By look she was normal .In first session she was hesitating to tell her problem but after some time  rapport was built and she told about her problem. She want to cope all that situation.She was looking weak and having dark circles around her eyes.In first session she gave the history of her problem.

Interview

Complete interview including personal history, family history, premorbid history, mental history etc was gathered from the client and attendant.

Mental Status examination

Well dressed
Good eye contact
Fully co-operative
Dark circles around   her eyes
Answered very well about every question

·    Formal Assessment

o    Suggested Names of Psychological Tests for Purpose of Diagnosis
­    HTP(House Tree Person Test)
­    BDI (Beck Depression Inventory)
­    RISB(Rotter’s Incomplete Sentence Blank)

Case formulation:

My client is 32 years old. She is the second last order among 5 siblings. She has good relation with her siblings. She was a good student. She was married to her cousin. In the beginning she ha good relations with him and was quite satisfied wither husband. Her husband told her to took care of his mother who was a psychotic patient. Her husband was not sexually capable to have sexual relationship. But she was did not argument on that because he was her cousin and she loved her. Her family knew that she is looking after her mother in law. After the death of her mother in law her mother asked about pregnancy she avoided.  But when her mother forced she told her about her husband’s problem. Her mother forced her to take divorce. But she refused. Her life was going good she was quite satisfied. But not after operating her uterus her husband want to marry again with another woman. She feels that may be I m not more beautiful or when I was medically able to conceive a baby then he did not get treatment but now he is getting. Worthlessness and guilt feelings are occurring in her. She is unable to do her responsibilities. Most of the time she is sad and negative feelings about herself come in to her mind. Different assessment suggest that the client is suffering from depression.

·    UC Researches Depression in Women
With women twice as likely to suffer from depression as men, researchers continue to ask why they are so vulnerable and to seek new medications to treat the widespread problem.

Researchers at the UC Medical Center Women's Health Research Program, one of few groups in the country that focus on causes and treatments of disorders that predominately affect women, are investigating a new medication that shows promise in alleviating the effects of depression.
Women suffering from depression are invited to participate in the study, during which they will receive free study-related medication and evaluations.
Typical symptoms of depression include feeling sad or down, losing interest in usual activities, feelings of guilt, worthlessness, or hopelessness, and sleeplessness or lack of energy.
Lesley M. Arnold, MD, director of the Women's Health Research Program, says although it's not certain why women are more prone to depression than men, there is some evidence of a genetic link.

Dr. Arnold, an associate professor of psychiatry, says women "may inherit a propensity to become depressed in response to stress."

There's also evidence, Dr. Arnold says, that healthy women produce less serotonin, an important neurotransmitter involved in mood regulation, than men.

"We suspect that stress depletes serotonin," Dr. Arnold says, "so if you start with lower levels, as women do,  serotonin could be depleted more easily, making women more susceptible to depression."

Depression is just one of the program's research interests. Investigators are also studying fibromyalgia, a chronic pain condition that is much more common in women than in men. Fibromyalgia is associated with fatigue, sleep disturbance and several other symptoms.
·    According to Hegadoren, a key factor in the development of depression in women is stress. Indeed, the most common response to a serious stressor in women is depression.
Hegadoren's research focuses on understanding the complex social, psychological, and biological factors that contribute to depression in women. She also looks at the factors that affect women's responses to antidepressant drug therapy.
In her studies with women, Hegadoren looks at the impact of stressful life experiences on women's health in a number of ways, including looking at whether stressors produce psychological symptoms like depression and anxiety, and examining stress hormone systems to see if past stressors have produced long term changes. Hegadoren explains that looking at changes in the stress hormone system might provide a means to differentiate between types of depression and to help predict response to treatment using antidepressant drug therapy.
Many women are relieved to discover there is a scientific way to determine the difference between their stress hormone levels and those of other people. "It validates them," says Hegadoren, "but it is also scary because it shows that they've been fundamentally changed by life events."
As an analogy, she points out that diabetes is also a scary thing to have, but since it can have many effects on long-term health, it has to be managed on a daily basis. "In the same way, knowing that their bodies have a decreased ability to deal with stress can give people power, because they can learn daily strategies to take care of their own mental health."
One of the positive outcomes of looking at stress adaptation in women is that it also suggests means of intervention based on building resilience and focusing on increasing coping strategies. For a significant percentage of women with depression, antidepressant therapy alone is insufficient to provide full recovery from the pervasive symptoms of depression.

With prevalence rates for depression in women double that of men, it is a serious health issue for women. However, our knowledge of factors that contribute to the increased vulnerability of women remains inadequate. It is well known that female hormones contribute to mood changes in women and it is unclear as to the exact ways that these hormones affect various systems in our brain.

"There is a huge gap in our knowledge on how different stages in a woman's life cycle and in her menstrual cycle affects the effectiveness of specific drugs, including antidepressants," Hegadoren said. "We hope to bridge that gap."

·    The Consequences of Depressive Affect on Functioning in Relation to Cluster B Personality Disorder Features
Joshua D. Miller, Eric T. Gaughan, Lauren R. Pryor and Charles Kamen
The authors examined the effects of depressed affect (DA) on functioning measured by behavioral tasks pertaining to abstract reasoning, social functioning, and delay of gratification in relation to Cluster B personality disorder features (PDs) in a clinical sample. Individuals were randomly assigned to either a DA induction or control condition. Consistent with clinical conceptualizations, the authors expected that Cluster B PD symptoms would be related to maladaptive responding (e.g., poorer delay of gratification) when experiencing DA. As hypothesized, many of the relations between the Cluster B PDs and functioning were moderated by DA (e.g., borderline PD was negatively related to abstract reasoning, but only in the DA condition). However, many of the Cluster B PDs symptom counts were related to more adaptive responses in the DA condition (e.g., less aggressive social functioning, better delay of gratification). The authors speculate that individuals with Cluster B PDs may be more likely to respond maladaptive to alternative negative mood states, such as anger and fear.

Multiaxial Diagnosis

Axis I:  depression 296.2
Axis II: no diagnosis
Axis III: no diagnosis
Axis IV: marital problems, adjustment problems
Axis V: GAF score is 70 (they are transient and expectable reactions to psychosocial stresses; no more than slight impairment in social, occupational, or school functioning).

Prognosis

On the basis of observation case history, DSM IV TR client’s GAF score is 70 which show chances of improvement.

Goals:

Short term goals:

Short term goals of the treatment are following as:
·    First of all we will use relaxation technique to relax her.
·    Stressors that are caused by the environment its difficult to control them but the response of client toward that stressors can be control .First of all we will use relaxation technique to relax her.
·    As my clients have low self esteem to enhance her self esteem we will use appraisal statements for her so that she can feel better.
Long term goals:

In long term goals we will use (REBT) Cognitive therapy to remove her irrational thoughts.


Suggestions

·    Counseling.
·    Follow up continuing of sessions