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What Is a Case Study?

Weighing the pros and cons of this method of research

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

• Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
• Gives researchers the chance to collect information on why one strategy might be chosen over another
• Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

• It cannot necessarily be generalized to the larger population
• Cannot demonstrate cause and effect
• It may not be scientifically rigorous
• It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

• Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
• Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
• Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

• Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
• Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
• Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
• Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
• Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
• Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

• Archival records : Census records, survey records, and name lists are examples of archival records.
• Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
• Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
• Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
• Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
• Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

• Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
• Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
• Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
• Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

• Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
• Read examples of case studies to gain an idea about the style and format.
• Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Case Study Research Method in Psychology

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

Case studies are in-depth investigations of a person, group, event, or community. Typically, data is gathered from various sources using several methods (e.g., observations & interviews).

The case study research method originated in clinical medicine (the case history, i.e., the patient’s personal history). In psychology, case studies are often confined to the study of a particular individual.

The information is mainly biographical and relates to events in the individual’s past (i.e., retrospective), as well as to significant events that are currently occurring in his or her everyday life.

The case study is not a research method, but researchers select methods of data collection and analysis that will generate material suitable for case studies.

Freud (1909a, 1909b) conducted very detailed investigations into the private lives of his patients in an attempt to both understand and help them overcome their illnesses.

This makes it clear that the case study is a method that should only be used by a psychologist, therapist, or psychiatrist, i.e., someone with a professional qualification.

There is an ethical issue of competence. Only someone qualified to diagnose and treat a person can conduct a formal case study relating to atypical (i.e., abnormal) behavior or atypical development.

 Famous Case Studies

• Anna O – One of the most famous case studies, documenting psychoanalyst Josef Breuer’s treatment of “Anna O” (real name Bertha Pappenheim) for hysteria in the late 1800s using early psychoanalytic theory.
• Little Hans – A child psychoanalysis case study published by Sigmund Freud in 1909 analyzing his five-year-old patient Herbert Graf’s house phobia as related to the Oedipus complex.
• Bruce/Brenda – Gender identity case of the boy (Bruce) whose botched circumcision led psychologist John Money to advise gender reassignment and raise him as a girl (Brenda) in the 1960s.
• Genie Wiley – Linguistics/psychological development case of the victim of extreme isolation abuse who was studied in 1970s California for effects of early language deprivation on acquiring speech later in life.
• Phineas Gage – One of the most famous neuropsychology case studies analyzes personality changes in railroad worker Phineas Gage after an 1848 brain injury involving a tamping iron piercing his skull.

Clinical Case Studies

• Studying the effectiveness of psychotherapy approaches with an individual patient
• Assessing and treating mental illnesses like depression, anxiety disorders, PTSD
• Neuropsychological cases investigating brain injuries or disorders

Child Psychology Case Studies

• Studying psychological development from birth through adolescence
• Cases of learning disabilities, autism spectrum disorders, ADHD
• Effects of trauma, abuse, deprivation on development

Types of Case Studies

• Explanatory case studies : Used to explore causation in order to find underlying principles. Helpful for doing qualitative analysis to explain presumed causal links.
• Exploratory case studies : Used to explore situations where an intervention being evaluated has no clear set of outcomes. It helps define questions and hypotheses for future research.
• Descriptive case studies : Describe an intervention or phenomenon and the real-life context in which it occurred. It is helpful for illustrating certain topics within an evaluation.
• Multiple-case studies : Used to explore differences between cases and replicate findings across cases. Helpful for comparing and contrasting specific cases.
• Intrinsic : Used to gain a better understanding of a particular case. Helpful for capturing the complexity of a single case.
• Collective : Used to explore a general phenomenon using multiple case studies. Helpful for jointly studying a group of cases in order to inquire into the phenomenon.

Where Do You Find Data for a Case Study?

There are several places to find data for a case study. The key is to gather data from multiple sources to get a complete picture of the case and corroborate facts or findings through triangulation of evidence. Most of this information is likely qualitative (i.e., verbal description rather than measurement), but the psychologist might also collect numerical data.

1. Primary sources

• Interviews – Interviewing key people related to the case to get their perspectives and insights. The interview is an extremely effective procedure for obtaining information about an individual, and it may be used to collect comments from the person’s friends, parents, employer, workmates, and others who have a good knowledge of the person, as well as to obtain facts from the person him or herself.
• Observations – Observing behaviors, interactions, processes, etc., related to the case as they unfold in real-time.
• Documents & Records – Reviewing private documents, diaries, public records, correspondence, meeting minutes, etc., relevant to the case.

2. Secondary sources

• News/Media – News coverage of events related to the case study.
• Academic articles – Journal articles, dissertations etc. that discuss the case.
• Government reports – Official data and records related to the case context.
• Books/films – Books, documentaries or films discussing the case.

3. Archival records

Searching historical archives, museum collections and databases to find relevant documents, visual/audio records related to the case history and context.

Public archives like newspapers, organizational records, photographic collections could all include potentially relevant pieces of information to shed light on attitudes, cultural perspectives, common practices and historical contexts related to psychology.

4. Organizational records

Organizational records offer the advantage of often having large datasets collected over time that can reveal or confirm psychological insights.

Of course, privacy and ethical concerns regarding confidential data must be navigated carefully.

However, with proper protocols, organizational records can provide invaluable context and empirical depth to qualitative case studies exploring the intersection of psychology and organizations.

• Organizational/industrial psychology research : Organizational records like employee surveys, turnover/retention data, policies, incident reports etc. may provide insight into topics like job satisfaction, workplace culture and dynamics, leadership issues, employee behaviors etc.
• Clinical psychology : Therapists/hospitals may grant access to anonymized medical records to study aspects like assessments, diagnoses, treatment plans etc. This could shed light on clinical practices.
• School psychology : Studies could utilize anonymized student records like test scores, grades, disciplinary issues, and counseling referrals to study child development, learning barriers, effectiveness of support programs, and more.

How do I Write a Case Study in Psychology?

Follow specified case study guidelines provided by a journal or your psychology tutor. General components of clinical case studies include: background, symptoms, assessments, diagnosis, treatment, and outcomes. Interpreting the information means the researcher decides what to include or leave out. A good case study should always clarify which information is the factual description and which is an inference or the researcher’s opinion.

1. Introduction

• Provide background on the case context and why it is of interest, presenting background information like demographics, relevant history, and presenting problem.
• Compare briefly to similar published cases if applicable. Clearly state the focus/importance of the case.

2. Case Presentation

• Describe the presenting problem in detail, including symptoms, duration,and impact on daily life.
• Include client demographics like age and gender, information about social relationships, and mental health history.
• Describe all physical, emotional, and/or sensory symptoms reported by the client.
• Use patient quotes to describe the initial complaint verbatim. Follow with full-sentence summaries of relevant history details gathered, including key components that led to a working diagnosis.
• Summarize clinical exam results, namely orthopedic/neurological tests, imaging, lab tests, etc. Note actual results rather than subjective conclusions. Provide images if clearly reproducible/anonymized.
• Clearly state the working diagnosis or clinical impression before transitioning to management.

3. Management and Outcome

• Indicate the total duration of care and number of treatments given over what timeframe. Use specific names/descriptions for any therapies/interventions applied.
• Present the results of the intervention,including any quantitative or qualitative data collected.
• For outcomes, utilize visual analog scales for pain, medication usage logs, etc., if possible. Include patient self-reports of improvement/worsening of symptoms. Note the reason for discharge/end of care.

4. Discussion

• Analyze the case, exploring contributing factors, limitations of the study, and connections to existing research.
• Analyze the effectiveness of the intervention,considering factors like participant adherence, limitations of the study, and potential alternative explanations for the results.
• Identify any questions raised in the case analysis and relate insights to established theories and current research if applicable. Avoid definitive claims about physiological explanations.
• Offer clinical implications, and suggest future research directions.

5. Additional Items

• Thank specific assistants for writing support only. No patient acknowledgments.
• References should directly support any key claims or quotes included.
• Use tables/figures/images only if substantially informative. Include permissions and legends/explanatory notes.
• Provides detailed (rich qualitative) information.
• Provides insight for further research.
• Permitting investigation of otherwise impractical (or unethical) situations.

Case studies allow a researcher to investigate a topic in far more detail than might be possible if they were trying to deal with a large number of research participants (nomothetic approach) with the aim of ‘averaging’.

Because of their in-depth, multi-sided approach, case studies often shed light on aspects of human thinking and behavior that would be unethical or impractical to study in other ways.

Research that only looks into the measurable aspects of human behavior is not likely to give us insights into the subjective dimension of experience, which is important to psychoanalytic and humanistic psychologists.

Case studies are often used in exploratory research. They can help us generate new ideas (that might be tested by other methods). They are an important way of illustrating theories and can help show how different aspects of a person’s life are related to each other.

The method is, therefore, important for psychologists who adopt a holistic point of view (i.e., humanistic psychologists ).

Limitations

• Lacking scientific rigor and providing little basis for generalization of results to the wider population.
• Researchers’ own subjective feelings may influence the case study (researcher bias).
• Difficult to replicate.
• Time-consuming and expensive.
• The volume of data, together with the time restrictions in place, impacted the depth of analysis that was possible within the available resources.

Because a case study deals with only one person/event/group, we can never be sure if the case study investigated is representative of the wider body of “similar” instances. This means the conclusions drawn from a particular case may not be transferable to other settings.

Because case studies are based on the analysis of qualitative (i.e., descriptive) data , a lot depends on the psychologist’s interpretation of the information she has acquired.

This means that there is a lot of scope for Anna O , and it could be that the subjective opinions of the psychologist intrude in the assessment of what the data means.

For example, Freud has been criticized for producing case studies in which the information was sometimes distorted to fit particular behavioral theories (e.g., Little Hans ).

This is also true of Money’s interpretation of the Bruce/Brenda case study (Diamond, 1997) when he ignored evidence that went against his theory.

Breuer, J., & Freud, S. (1895).  Studies on hysteria . Standard Edition 2: London.

Curtiss, S. (1981). Genie: The case of a modern wild child .

Diamond, M., & Sigmundson, K. (1997). Sex Reassignment at Birth: Long-term Review and Clinical Implications. Archives of Pediatrics & Adolescent Medicine , 151(3), 298-304

Freud, S. (1909a). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Freud, S. (1909b). Bemerkungen über einen Fall von Zwangsneurose (Der “Rattenmann”). Jb. psychoanal. psychopathol. Forsch ., I, p. 357-421; GW, VII, p. 379-463; Notes upon a case of obsessional neurosis, SE , 10: 151-318.

Harlow J. M. (1848). Passage of an iron rod through the head.  Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868).  Recovery from the Passage of an Iron Bar through the Head .  Publications of the Massachusetts Medical Society. 2  (3), 327-347.

Money, J., & Ehrhardt, A. A. (1972).  Man & Woman, Boy & Girl : The Differentiation and Dimorphism of Gender Identity from Conception to Maturity. Baltimore, Maryland: Johns Hopkins University Press.

Money, J., & Tucker, P. (1975). Sexual signatures: On being a man or a woman.

Further Information

• Case Study Approach
• Case Study Method
• Enhancing the Quality of Case Studies in Health Services Research
• “We do things together” A case study of “couplehood” in dementia
• Using mixed methods for evaluating an integrative approach to cancer care: a case study

How to Write a Case Conceptualization: 10 Examples (+ PDF)

Such understanding can be developed by reading relevant records, meeting with clients face to face, and using assessments such as a mental status examination.

As you proceed, you are forming a guiding concept of who this client is, how they became who they are, and where their personal journey might be heading.

Such a guiding concept, which will shape any needed interventions, is called a case conceptualization, and we will examine various examples in this article.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into positive Cognitive-Behavioral Therapy (CBT) and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is a case conceptualization or formulation, 4 things to include in your case formulation, a helpful example & model, 3 samples of case formulations, 6 templates and worksheets for counselors, relevant resources from positivepsychology.com, a take-home message.

In psychology and related fields, a case conceptualization summarizes the key facts and findings from an evaluation to provide guidance for recommendations.

This is typically the evaluation of an individual, although you can extend the concept of case conceptualization to summarizing findings about a group or organization.

Based on the case conceptualization, recommendations can be made to improve a client’s self-care , mental status, job performance, etc (Sperry & Sperry, 2020).

• Summary of the client’s identifying information, referral questions, and timeline of important events or factors in their life . A timeline can be especially helpful in understanding how the client’s strengths and limitations have evolved.
• Statement of the client’s core strengths . Identifying core strengths in the client’s life should help guide any recommendations, including how strengths might be used to offset limitations.
• Statement concerning a client’s limitations or weaknesses . This will also help guide any recommendations. If a weakness is worth mentioning in a case conceptualization, it is worth writing a recommendation about it.

Note: As with mental status examinations , observations in this context concerning weaknesses are not value judgments, about whether the client is a good person, etc. The observations are clinical judgments meant to guide recommendations.

• A summary of how the strengths, limitations, and other key information about a client inform diagnosis and prognosis .

You should briefly clarify how you arrived at a given diagnosis. For example, why do you believe a personality disorder is primary, rather than a major depressive disorder?

Many clinicians provide diagnoses in formal psychiatric terms, per the International Classification of Diseases (ICD-10) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Some clinicians will state a diagnosis in less formal terms that do not coincide exactly with ICD-10 or DSM-5 codes. What is arguably more important is that a diagnostic impression, formal or not, gives a clear sense of who the person is and the support they need to reach their goals.

Prognosis is a forecast about whether the client’s condition can be expected to improve, worsen, or remain stable. Prognosis can be difficult, as it often depends on unforeseeable factors. However, this should not keep you from offering a conservative opinion on a client’s expected course, provided treatment recommendations are followed.

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Based on the pointers for writing a case conceptualization above, an example for summarizing an adolescent case (in this instance, a counseling case for relieving depression and improving social skills) might read as follows.

Background and referral information

This is a 15-year-old Haitian–American youth, referred by his mother for concerns about self-isolation, depression, and poor social skills. He reportedly moved with his mother to the United States three years ago.

He reportedly misses his life and friends in Haiti. The mother states he has had difficulty adjusting socially in the United States, especially with peers. He has become increasingly self-isolating, appears sad and irritable, and has started to refuse to go to school.

His mother is very supportive and aware of his emotional–behavioral needs. The youth has been enrolled in a social skills group at school and has attended three sessions, with some reported benefit. He is agreeable to start individual counseling. He reportedly does well in school academically when he applies himself.

Limitations

Behavioral form completed by his mother shows elevated depression scale (T score = 80). There is a milder elevation on the inattention scale (T score = 60), which suggests depression is more acute than inattention and might drive it.

He is also elevated on a scale measuring social skills and involvement (T score = 65). Here too, it is reasonable to assume that depression is driving social isolation and difficulty relating to peers, especially since while living in Haiti, he was reportedly quite social with peers.

Diagnostic impressions, treatment guidance, prognosis

This youth’s history, presentation on interview, and results of emotional–behavioral forms suggest some difficulty with depression, likely contributing to social isolation. As he has no prior reported history of depression, this is most likely a reaction to missing his former home and difficulty adjusting to his new school and peers.

Treatments should include individual counseling with an evidence-based approach such as Cognitive-Behavioral Therapy (CBT). His counselor should consider emotional processing and social skills building as well.

Prognosis is favorable, with anticipated benefit apparent within 12 sessions of CBT.

How to write a case conceptualization: An outline

The following outline is necessarily general. It can be modified as needed, with points excluded or added, depending on the case.

• Client’s gender, age, level of education, vocational status, marital status
• Referred by whom, why, and for what type of service (e.g., testing, counseling, coaching)
• In the spirit of strengths-based assessment, consider listing the client’s strengths first, before any limitations.
• Consider the full range of positive factors supporting the client.
• Physical health
• Family support
• Financial resources
• Capacity to work
• Resilience or other positive personality traits
• Emotional stability
• Cognitive strengths, per history and testing
• The client’s limitations or relative weaknesses should be described in a way that highlights those most needing attention or treatment.
• Medical conditions affecting daily functioning
• Lack of family or other social support
• Limited financial resources
• Inability to find or hold suitable employment
• Substance abuse or dependence
• Proneness to interpersonal conflict
• Emotional–behavioral problems, including anxious or depressive symptoms
• Cognitive deficits, per history and testing
• Diagnoses that are warranted can be given in either DSM-5 or ICD-10 terms.
• There can be more than one diagnosis given. If that’s the case, consider describing these in terms of primary diagnosis, secondary diagnosis, etc.
• The primary diagnosis should best encompass the client’s key symptoms or traits, best explain their behavior, or most need treatment.
• Take care to avoid over-assigning multiple and potentially overlapping diagnoses.

When writing a case conceptualization, always keep in mind the timeline of significant events or factors in the examinee’s life.

• Decide which events or factors are significant enough to include in a case conceptualization.
• When these points are placed in a timeline, they help you understand how the person has evolved to become who they are now.
• A good timeline can also help you understand which factors in a person’s life might be causative for others. For example, if a person has suffered a frontal head injury in the past year, this might help explain their changeable moods, presence of depressive disorder, etc.

Sample #1: Conceptualization for CBT case

This is a 35-year-old Caucasian man referred by his physician for treatment of generalized anxiety.

Strengths/supports in his case include willingness to engage in treatment, high average intelligence per recent cognitive testing, supportive family, and regular physical exercise (running).

Limiting factors include relatively low stress coping skills, frequent migraines (likely stress related), and relative social isolation (partly due to some anxiety about social skills).

The client’s presentation on interview and review of medical/psychiatric records show a history of chronic worry, including frequent worries about his wife’s health and his finances. He meets criteria for DSM-5 generalized anxiety disorder. He has also described occasional panic-type episodes, which do not currently meet full criteria for panic disorder but could develop into such without preventive therapy.

Treatments should include CBT for generalized anxiety, including keeping a worry journal; regular assessment of anxiety levels with Penn State Worry Questionnaire and/or Beck Anxiety Inventory; cognitive restructuring around negative beliefs that reinforce anxiety; and practice of relaxation techniques, such as progressive muscle relaxation and diaphragmatic breathing .

Prognosis is good, given the evidence for efficacy of CBT for anxiety disorders generally (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012).

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Sample #2: Conceptualization for DBT case

This 51-year-old Haitian–American woman is self-referred for depressive symptoms, including reported moods of “rage,” “sadness,” and “emptiness.” She says that many of her difficulties involve family, friends, and coworkers who regularly “disrespect” her and “plot against her behind her back.”

Her current psychiatrist has diagnosed her with personality disorder with borderline features, but she doubts the accuracy of this diagnosis.

Strengths/supports include a willingness to engage in treatment, highly developed and marketable computer programming skills, and engagement in leisure activities such as playing backgammon with friends.

Limiting factors include low stress coping skills, mild difficulties with attention and recent memory (likely due in part to depressive affect), and a tendency to self-medicate with alcohol when feeling depressed.

The client’s presentation on interview, review of medical/psychiatric records, and results of MMPI-2 personality inventory corroborate her psychiatrist’s diagnosis of borderline personality disorder.

The diagnosis is supported by a longstanding history of unstable identity, volatile personal relationships with fear of being abandoned, feelings of emptiness, reactive depressive disorder with suicidal gestures, and lack of insight into interpersonal difficulties that have resulted in her often stressed and depressive state.

Treatments should emphasize a DBT group that her psychiatrist has encouraged her to attend but to which she has not yet gone. There should also be regular individual counseling emphasizing DBT skills including mindfulness or present moment focus, building interpersonal skills, emotional regulation, and distress tolerance. There should be a counseling element for limiting alcohol use. Cognitive exercises are also recommended.

Of note, DBT is the only evidence-based treatment for borderline personality disorder (May, Richardi, & Barth, 2016). Prognosis is guardedly optimistic, provided she engages in both group and individual DBT treatments on a weekly basis, and these treatments continue without interruption for at least three months, with refresher sessions as needed.

Sample #3: Conceptualization in a family therapy case

This 45-year-old African-American woman was initially referred for individual therapy for “rapid mood swings” and a tendency to become embroiled in family conflicts. Several sessions of family therapy also appear indicated, and her psychiatrist concurs.

The client’s husband (50 years old) and son (25 years old, living with parents) were interviewed separately and together. When interviewed separately, her husband and son each indicated the client’s alcohol intake was “out of control,” and that she was consuming about six alcoholic beverages throughout the day, sometimes more.

Her husband and son each said the client was often too tired for household duties by the evening and often had rapid shifts in mood from happy to angry to “crying in her room.”

On individual interview, the client stated that her husband and son were each drinking about as much as she, that neither ever offered to help her with household duties, and that her son appeared unable to keep a job, which left him home most of the day, making demands on her for meals, etc.

On interview with the three family members, each acknowledged that the instances above were occurring at home, although father and son tended to blame most of the problems, including son’s difficulty maintaining employment, on the client and her drinking.

Strengths/supports in the family include a willingness of each member to engage in family sessions, awareness of supportive resources such as assistance for son’s job search, and a willingness by all to examine and reduce alcohol use by all family members as needed.

Limiting factors in this case include apparent tendency of all household members to drink to some excess, lack of insight by one or more family members as to how alcohol consumption is contributing to communication and other problems in the household, and a tendency by husband and son to make this client the family scapegoat.

The family dynamic can be conceptualized in this case through a DBT lens.

From this perspective, problems develop within the family when the environment is experienced by one or more members as invalidating and unsupportive. DBT skills with a nonjudgmental focus, active listening to others, reflecting each other’s feelings, and tolerance of distress in the moment should help to develop an environment that supports all family members and facilitates effective communication.

It appears that all family members in this case would benefit from engaging in the above DBT skills, to support and communicate with one another.

Prognosis is guardedly optimistic if family will engage in therapy with DBT elements for at least six sessions (with refresher sessions as needed).

Introduction to case conceptualization – Thomas Field

The following worksheets can be used for case conceptualization and planning.

• Case Conceptualization Worksheet: Individual Counseling helps counselors develop a case conceptualization for individual clients.
• Case Conceptualization Worksheet: Couples Counseling helps counselors develop a case conceptualization for couples.
• Case Conceptualization Worksheet: Family Counseling helps counselors develop a case conceptualization for families.
• Case Conceptualization and Action Plan: Individual Counseling helps clients facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Couples Counseling helps couples facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Family Counseling helps families facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.

17 Science-Based Ways To Apply Positive CBT

These 17 Positive CBT & Cognitive Therapy Exercises [PDF] include our top-rated, ready-made templates for helping others develop more helpful thoughts and behaviors in response to challenges, while broadening the scope of traditional CBT.

Created by Experts. 100% Science-based.

The following resources can be found in the Positive Psychology Toolkit© , and their full versions can be accessed by a subscription.

Analyzing Strengths Use in Different Life Domains can help clients understand their notable strengths and which strengths can be used to more advantage in new contexts.

Family Strength Spotting is another relevant resource. Each family member fills out a worksheet detailing notable strengths of other family members. In reviewing all worksheets, each family member can gain a greater appreciation for other members’ strengths, note common or unique strengths, and determine how best to use these combined strengths to achieve family goals.

Four Front Assessment is another resource designed to help counselors conceptualize a case based on a client’s personal and environmental strengths and weaknesses. The idea behind this tool is that environmental factors in the broad sense, such as a supportive/unsupportive family, are too often overlooked in conceptualizing a case.

If you’re looking for more science-based ways to help others through CBT, check out this collection of 17 validated positive CBT tools for practitioners. Use them to help others overcome unhelpful thoughts and feelings and develop more positive behaviors.

In helping professions, success in working with clients depends first and foremost on how well you understand them.

This understanding is crystallized in a case conceptualization.

Case conceptualization helps answer key questions. Who is this client? How did they become who they are? What supports do they need to reach their goals?

The conceptualization itself depends on gathering all pertinent data on a given case, through record review, interview, behavioral observation, questionnaires completed by the client, etc.

Once the data is assembled, the counselor, coach, or other involved professional can focus on enumerating the client’s strengths, weaknesses, and limitations.

It is also often helpful to put the client’s strengths and limitations in a timeline so you can see how they have evolved and which factors might have contributed to the emergence of others.

Based on this in-depth understanding of the client, you can then tailor specific recommendations for enhancing their strengths, overcoming their weaknesses, and reaching their particular goals.

We hope you have enjoyed this discussion of how to conceptualize cases in the helping professions and that you will find some tools for doing so useful.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

• Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research , 36 (5), 427–440.
• May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. The Mental Health Clinician , 6 (2), 62–67.
• Sperry, L., & Sperry, J. (2020).  Case conceptualization: Mastering this competency with ease and confidence . Routledge.

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Introduction to Psychological Assessment

• First Online: 14 May 2021

Cite this chapter

• Cecil R. Reynolds 4 ,
• Robert A. Altmann 5 &
• Daniel N. Allen 6  

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Psychological testing and assessment are important in virtually every aspect of professional psychology. Assessment has widespread application in health, educational, occupational, forensic, research, and other settings. This chapter provides a historical and theoretical introduction to psychological testing, discussing basic terminology, major types of psychological tests, and types of scores that are used for interpreting results. Assumptions that underlie psychological assessment are considered as well as the rationale for using tests to make important decisions about people. Common applications and common criticisms of testing and assessment are reviewed, and characteristics of those involved in the testing process are presented. The chapter ends with a discussion of expected changes to current testing to meet new demands for test applications in the twenty-first century.

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A Case Study in Attention-Deficit/Hyperactivity Disorder: An Innovative Neurofeedback-Based Approach

Associated data.

The data presented in this study are available on request from the corresponding author.

In research about attention-deficit/hyperactivity disorder (ADHD) there is growing interest in evaluating cortical activation and using neurofeedback in interventions. This paper presents a case study using monopolar electroencephalogram recording (brain mapping known as MiniQ) for subsequent use in an intervention with neurofeedback for a 10-year-old girl presenting predominantly inattentive ADHD. A total of 75 training sessions were performed, and brain wave activity was assessed before and after the intervention. The results indicated post-treatment benefits in the beta wave (related to a higher level of concentration) and in the theta/beta ratio, but not in the theta wave (related to higher levels of drowsiness and distraction). These instruments may be beneficial in the evaluation and treatment of ADHD.

1. Introduction

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood disorders, affecting between 5.9% and 7.2% of the infant and adolescent population. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [ 1 ] describes ADHD as a neurodevelopmental disorder characterized by a persistent pattern of inattention, hyperactivity, and impulsivity manifesting in children before the age of 12 years old more frequently and with greater severity than expected in children of equivalent ages. Depending on the predominant symptoms, three types of presentation may be identified: predominantly hyperactive-impulsive, predominantly inattentive, and combined. There are two theories that attempt to explain the neurophysiological nature and characteristics of ADHD. Mirsky posited a deficit in attention as the main focus in ADHD, such that the failure is found in processes of activation [ 2 ]. The other theory was proposed by Barkley, who attributed the problems of ADHD to a deficit in behavioral regulation, where processes associated with the frontal cortex fail [ 3 ].

The determination of ADHD symptoms, along with the underlying neuropsychology, as outlined by the theories above, have led in recent years to the incorporation of evaluation and intervention techniques that do not solely focus on the behavioral aspects of the disorder. More specifically, techniques such as electroencephalography in ADHD evaluation and neurofeedback in interventions may provide greater benefits in detection and treatment.

The present study analyzes a specific case of ADHD with predominantly inattentive presentation, covering monopolar electroencephalogram recording (brain mapping called MiniQ) and intervention via neurofeedback.

The study was approved by the relevant Ethics Committee of the Principality of Asturias (reference: PMP/ICH/135/95; code: TDAH-Oviedo), and all procedures complied with relevant laws and institutional guidelines.

1.1. Evaluation of ADHD

The current diagnostic criteria for ADHD can be found in the DSM-5 [ 1 ] and in the International Statistical Classification of Diseases and Related Health Problems, eleventh revision, from the World Health Organization [ 4 ]. Various evaluation instruments are used to identify ADHD, from general assessments via broad scales such as the Wechsler scale, to more specific tests assessing execution (e.g., test of variables of attention, D2 attention test), symptoms (e.g., Conners scale, EDAH scale), and the evaluation of cortical activity (e.g., using quantitative electroencephalograms, qEEG).

One alternative to qEEG is monopolar EEG recording (fundamentally used in clinical practice), called MiniQ (software Biograph Infinity, ThoughtTech, Montreal, QC, Canada). The MiniQ is an instrument for evaluating brain waves from 12 cortical locations (international 10/20 system) [ 5 ]. This type of evaluation (monopolar EEG, MiniQ) lies somewhere between the traditional baseline (single-channel qEEG) and full brain mapping. The frequency ranges evaluated match the classics [ 6 , 7 ]: delta 1–4 Hz, theta 4–8 Hz, alpha 8–12 Hz, sensorimotor rhythm SMR 12–15 Hz, beta 13–21 Hz, beta3 or high beta 20–32 Hz, and gamma 38–42 Hz. Theta waves have been related to low activation, sleep states, and low levels of awareness, beta and alpha waves have been associated with higher levels of attention and concentration [ 8 ]. In addition, the MiniQ, in line with qEEG, provides the relationships or ratios of theta/alpha, theta/beta, SMR/theta and peak alpha. Previous research has established that the ratio between theta and beta waves is a better indicator of brain activity than each wave taken separately (see Rodríguez et al. [ 9 ]). Monastra et al. attempted to establish what values of the theta/beta ratio would be compatible with those seen in subjects with ADHD [ 7 ]. They indicated critical values (cutoff points) for ADHD in theta/beta absolute power ratio, using 1.5 standard deviations compared to the control groups and based on age, those cutoff points are: 4.36 (6–11 years old), 2.89 (12–15 years old), 2.24 (16–20 years old), and 1.92 (21–30 years old). Higher values than the cutoff points would indicate a profile that is compatible with a subject with ADHD.

The distribution of electrical brain activity must be analyzed considering each site and the expected frequency. A regulated subject is characterized by more rapid activity in the frontal regions (predominantly beta) which decreases toward the posterior (occipital) regions, where slower waves (theta and delta) are expected [ 10 , 11 ]. Slower brainwaves are expected to predominate in the right hemisphere compared to the left, in which faster waves predominate. More specifically, beta waves will predominate in the left hemisphere, alpha waves in the right hemisphere, and there will be similar levels of theta waves in both. In addition, during a task (e.g., reading or arithmetic) rapid (beta) waves are expected to increase.

In contrast, the electrical activity in a subject with predominantly inattentive ADHD is characterized by a predominance of theta waves (compared to beta) in the frontal regions, particularly on the left (F3). During tasks (e.g., reading or arithmetic), a subject with predominantly inattentive ADHD will exhibit increased slower (theta) waves, and there will be a slowdown in the frontal regions that hinders attentional quality, as suggested by researchers such as Clarke et al. [ 10 ] and more recently, Kerson et al. [ 12 ]. Studying the profile of cortical activation allows suitable intervention protocols to be established and tailored to each subject.

1.2. ADHD Intervention

Many studies have examined the efficacy of the various treatments and interventions aimed at improving symptoms associated with ADHD (inattention, hyperactivity, and impulsivity), such as medication, behavioral treatments, and neurofeedback (see Caye et al. [ 13 ]). Neurofeedback is a type of biofeedback which aims for the subject to be aware of their brain activity and to be able to regulate it via classical conditioning processes [ 14 , 15 ]. In neurofeedback training, a subject’s electrical brain activity is recorded via an electroencephalograph, and the signal is filtered and exported to a computer. Software then transforms and quantifies the brainwaves, presenting them in the form of a game with movement or sounds which give the subject feedback about their brain activity [ 16 ].

The use of neurofeedback in interventions for ADHD began in 1973, although the first study with positive results was published in 1976 [ 17 ]. Since then, various studies have reported benefits from using neurofeedback in infants, with improvements in behavior, attention, and impulsivity control (e.g., [ 18 , 19 , 20 , 21 , 22 ]). A meta-analysis by Arns et al. [ 14 ] concluded that treatment of ADHD with neurofeedback could be considered “effective and specific”, with a large effect size for attention deficit and impulsivity and a moderate effect size for hyperactivity. In a systematic review and meta-analysis, Van Doren et al. [ 21 ] found that neurofeedback demonstrated moderate benefits for attention and hyperactivity-impulsivity, which were maintained in subsequent follow-ups (between 2 and 12 months after the intervention). However, in a recent meta-analysis aimed at comparing the effects of methylphenidate and neurofeedback on the main symptoms of ADHD, Yan et al. [ 20 ] found methylphenidate to be better than neurofeedback, although the authors highlighted that the results were inconsistent between evaluators.

Neurofeedback training is normally done two or three times a week, and around 40 sessions are needed to see changes in symptomatology [ 13 ]. Although it is an expensive treatment that needs consistency and continuity, in the USA, around 10% of children and adolescents with ADHD have received neurofeedback [ 23 ]. The benefits of neurofeedback training may depend on the type of protocol used. The three most-commonly used protocols in subjects with ADHD are [ 14 ]: (1) theta/beta ratio; (2) sensorimotor rhythm, SMR; and (3) slow cortical potential. The most widely used of these three protocols is the theta/beta ratio, based on inhibition of theta and increasing beta, which usually improves SMR at the same time [ 13 ]. However, it is important to note that there is no recommended standard about the number, time or frequency of sessions, and there is no standard placement of NF screening when this type of protocol is administered [ 24 , 25 ]. In this context, the present study aims to provide a structure in which the neurofeedback intervention is adjusted based on the data provided by the previous assessment in a specific case.

The intervention protocol must be tailored to each individual case based on prior assessment, especially when using results from tests such as the MiniQ. In this context, the objective of the current study is to present the process of analyzing brainwaves in a case with ADHD (predominantly inattentive presentation) via the MiniQ test, the protocol for intervention using neurofeedback, and its efficacy. Although the alteration of brainwaves in specific areas in subjects with ADHD is well documented, and the efficacy of neurofeedback has been observed in various studies, the present study aims to provide a specific procedure for assessment and intervention. Researchers and professionals need specific protocols and procedures that allow them to determine what is effective for each individual case.

2. Methodology

2.1. description of the case.

This was a case study using monopolar electroencephalogram recording (brain mapping known as MiniQ) for subsequent use in an intervention with neurofeedback for a 10-year-old girl presenting predominantly inattentive ADHD.

2.1.1. Patient Identification

The subject was a 10-year-old girl in the fourth year of primary education. Her academic performance was poor, with the worst results in language, social sciences, and science. She found it difficult to go to school and was shy and reserved. She was the younger of two sisters, the older being an outstanding pupil. Her mother characterized her as a quiet girl who needed a lot of time to do any kind of task. In addition, during the study and academic tasks, she would often gaze into space, as if she were in her own world. Both her father and her mother evidenced concern for her school results, but also for her social relationships, as her self-absorption appeared in all contexts, making it hard for her to have conversations, pay attention to others, or follow the rules in games.

2.1.2. Reason for Consultation

The consultation was for poor academic performance, slowness doing tasks, and wandering attention from when she had started school, although that had increased in the previous year. Initially, the subject did not demonstrate any great willingness to attend the consultations, but over time, she demonstrated a participative attitude with good involvement in doing the tasks she was set.

2.1.3. History of the Problem

The subject’s school history was one of failure in the main school subjects. She had not had to repeat a school year, but her form tutors repeatedly raised this possibility with her parents. At the time of the study, there had been no clinical or educational psychology assessments. Previous diagnosis of ADHD was by her neuropediatrician one month before the assessment in the Psychology clinic consultation. From that point, guidelines were given for pharmacological treatment, which had not begun.

2.2. Proposed Evaluation and Intervention

2.2.1. evaluation: brainwave analysis with the miniq instrument.

An assessment was performed using a MiniQ (Monopolar, from Biograph Infinity). Assessment using the MiniQ is a two-step process (evaluation and interpretation) which is simple, relatively fast, and inexpensive.

The first step is to make the recording from the 12 cortical sites, which can be done with eyes closed or open, and either with or without tasks (reading or arithmetic). This gives information about the values of the different brainwaves at each site. To begin, electrodes are placed on the earlobes and two active electrodes in each of the sites indicated by the program. Before beginning the assessment for each site, the impedance level—the quality of the connection—for each of the electrodes must be checked, both on the ears and on the scalp, to avoid artefacts. When the impedance level is below 4, the recording process can begin. The subject is instructed to remain still and to look at the computer screen where there is an image of a landscape. They must keep their eyes open and keep silent. The program guides the application, which is based on the placement of electrodes in groups of two following the sequence: Cz–Fz, Cz–Pz, F3–F4, C3–C4, P3–P4, O1–O2, and T3–T4. For sites F3–F4, subjects are asked to read a story quietly and to do some simple arithmetic (e.g., 2 + 3, +5, +4, −1, +6, −3, etc.). Once recordings have been made at all of the sites, the program filters the data to remove artefacts. Finally, the recorded data is interpreted, and the values are analyzed, allowing the state of the subjects’ brainwaves to be determined. Applying the test takes approximately 60 min.

The second step is to analyze the collected data considering the site and the frequency ranges at each. The sites are labelled based on the four quadrants of the cortex: anterior, posterior, left hemisphere (odd numbers), and right hemisphere (even numbers). The instrument gives the results in two formats, an Excel spreadsheet and a PowerPoint. In addition to the measurements or wave values (delta, theta, alpha, sensorimotor rhythm SMR, beta, beta3, and gamma) at the sites noted above, the spreadsheet also includes the values for the ratios of theta/alpha, theta/beta, SMR/theta, and peak alpha. The PowerPoint presentation gives the same information, although over a background image of a brain, which allows scores to be seen at the relevant site (see Figure 1 ). With that information, it is possible to assess cerebral asymmetry, both anterior-posterior and right-left, according to each location.

Pre-treatment results from the MiniQ instrument. Note . T = theta; B = beta; T/B = theta/beta ratio. In subjects aged between 7 and 11 years old, values over 2.8 for the theta/beta ratio are compatible with a profile of ADHD.

The values of the theta/beta ratios are interpreted based on Monastra et al. (1999) [ 7 ], bearing in mind that in this case, the scores were relative power not absolute. Scores are indicative of ADHD when the values are over 2.5 for those up to 7 years old, over 2.8 for 7- to 11-year-olds, over 2.4 in adolescents, and over 1.8 in adults. Traditional ratios for ADHD indicators use absolute power values measured in peak volts (microvolts squared divided by the hertz value). Biograph for theta/beta ratio calculation uses relative power values (microvolts divided by the hertz value).

2.2.2. Intervention: Neurofeedback Protocols

The intervention was carried out using the Biograph Infiniti biofeedback software (Procomp2 from Thought Technology, Montreal, QC, Canada; https://thoughttechnology.com/ , accessed on 23 December 2021). Two protocols were used in the intervention process, an SMR protocol and a theta/beta protocol. The protocol and specific sites selected were based on the prior evaluation.

The SMR protocol used site Cz and was designed to work on three frequencies, theta, SMR, and beta3 [ 26 ]. The objective of this kind of protocol is to perform SMR (12–15 Hz) training to increase the production of this wave and inhibit the production of theta (4–7 Hz) and beta3 (20–32 Hz) activity. During the training sessions, the subject watches a videogame or a film on the screen. Following the neurofeedback dynamic, the game or the film progresses positively if the level of electrical activity increases and stops when the level of electrical activity falls. Reinforcement occurs when the value of theta and beta3 are below the set value and SMR is above a pre-determined threshold. The reinforcement consists of a sound and points awarded to the subject. The working thresholds are provided by the program automatically, although they can be modified manually by the therapist. The level of reinforcement is set by the therapist. Initially, it is set at 80%, and depending on how the subject masters the task, the reinforcement is reduced. The subject is not given explicit instructions about what they have to do; they are told “try to keep the animation on the screen moving”.

The theta/beta protocol works at site Fz. The aim of this protocol is to reduce the amplitude of theta waves and increase beta to work on concentration. The subject has to do tasks which consist of concentrating on a game that appears on the computer screen. The game presents a pink square (which represents the value of theta) and a blue square (representing the value of beta). The subject is told that the game involves trying to make the pink square as small as possible and the blue square as large as possible. The computer automatically generates the ranges over which the waves are worked, although they can be changed manually by the therapist. The desired working theta/beta ratio can also be set manually. The protocol begins with high ratios, close to three, such that the task is simple and the subject achieves reinforcement on many occasions. The ratio is progressively reduced according to the subject’s progress.

The intervention lasted for a year and consisted of 75 neurofeedback sessions. There were two phases to the training. The first phase, “the regulation phase”, covered the first 15 sessions, during which the SMR protocol was followed at Cz. The aim of this first phase was to strengthen SMR and inhibit theta and beta3 in the central region. These sessions were around 45 min each. To avoid tiredness, different presentations of neurofeedback were used (videogame or film) during the sessions, with five-minute breaks between each presentation.

The second phase ran from session 16 to session 75. In these sessions, the SMR protocol at Cz was applied for 20 min, followed by a five-minute break before the theta/beta protocol at Fz was applied for another 20 min. For the first six months of the intervention, sessions were 45 min, twice weekly. During the remaining six months, the sessions were weekly and remained 45 min long.

3.1. Brainwave Evaluation

Based on the information obtained over the evaluation of the case, and considering the prior diagnosis from her pediatric neurologist, the subject presented ADHD with predominantly inattentive presentation. As Figure 1 shows, her brainwave profile indicated scores for the theta/beta ratio of close to 2.8 in the central (Cz) and frontal regions (Fz). Considering the scores in Cz and Fz, the neurofeedback needed to include these sites. Furthermore, neurofeedback on frontal-midline theta (Fz) has been shown to be frequently more effective than neurofeedback protocols that do not include Fz [ 22 ].

Given the brainwave profile, the aim of the intervention was to reduce theta and increase beta in the frontal zones. That indicated using the SMR and theta/beta protocols [ 15 ].

3.2. Progression following Neurofeedback Intervention

Once the neurofeedback intervention was completed, brainwave activity was assessed again using the MiniQ. Figure 2 illustrates the change in theta, beta, and SMR, along with the theta/beta ratio at sites Cz and Fz. The results show a positive progression following the neurofeedback training.

Pre- and post-treatment activity in sites Cz and Fz.

Theta activity fell following the intervention, both at Fz (by 0.77) and at Cz (by 1.56). To put it another way, there was a reduction in the slow wave at both sites (mainly in the central region compared to the frontal region). This is in line with expected values of theta at the cortical level, as they should be higher in posterior areas and lower in frontal areas.

There was also an increase in beta at the two sites, with a 3.60-point increase at Fz and a 4.2-point increase at Cz. In this case, the intervention produced considerable increases in the rapid wave values at both sites, although the value was slightly higher in the central area than in the frontal. Values for beta waves are expected to be higher in frontal areas than central areas, and although that was not the case here, the values were very close. The SMR wave also increased notably, by 2.57 points at Fz and 2.89 points at Cz. In short, the intervention led to a slight reduction in the slow wave, with lower values at post-treatment (less distraction), and increases in fast waves, beta, and SMR, with higher values after the intervention (better ability to concentrate). The theta/beta ratio also decreased at post-treatment (basically due to the increase in beta), both at Fz (by 0.69) and Cz (by 0.96), from values close to those for ADHD to scores more indicative of a subject without ADHD.

In addition, as initially proposed, the assessment with the MiniQ also considered the subject’s activation levels during reading and arithmetic tasks. Measurement of these values was at sites F3 and F4. The subject did three types of task for two minutes each: Paying attention to the screen on which a landscape appeared, reading a story, and doing simple arithmetic (addition and subtraction). As Figure 3 shows, post-treatment scores were different than pre-treatment scores.

Pre- and post-treatment evolution in F3 and F4 areas with and without tasks.

In the first task (pay attention to the screen), the values for theta, beta, and beta3 at F3 and F4 all rose. In the second and third tasks (reading and arithmetic), there were variations in all of the waves, both slow and fast. These results indicate that there was no improvement during tasks following the intervention, because although the fast waves (beta and beta3) increased, the slow wave (theta) did not diminish. Following the intervention, the expectation was to have increased levels of beta and beta3 (especially at F3), while reducing levels of theta. However, as Figure 3 shows, the theta/beta ratio fell, with lower values post-treatment.

4. Discussion

The aim of this study was to present the process for detecting a case of ADHD (predominantly inattentive presentation) using the MiniQ test, along with the neurofeedback intervention protocol and its efficacy. In terms of detection, the MiniQ showed the subjects’ brain activity, which together with behavioral symptoms, provided details of their characteristic profile and allowed tailored treatment. Various studies in the literature have concluded that children with ADHD exhibit higher levels of theta waves and lower levels of beta waves, particularly in frontal areas [ 10 , 11 ]. In addition, the relationship between the theta and beta waves (the theta/beta ratio) had already been associated with ADHD symptomatology through the research by Monastra et al. [ 7 ] and Jarrett et al. [ 27 ].

In the current case study, the MiniQ was relatively simple to apply, and it provided large amounts of information related to brainwave values at the 12 different sites. More specifically, the EEG record of the 10-year-old subject showed lower levels of beta activity in the frontal regions and a higher level of theta activity in the frontal and central regions. However, the slow wave (theta) should be higher in posterior regions and fall in the central area, whereas the fast waves (beta and beta3) should be higher in the anterior regions and lower in the posterior. The subject’s theta/beta ratio was high (Cz: 2.05) and close to values seen in subjects with ADHD according to Monastra et al. [ 7 ]. and Jarrett et al. [ 27 ]. Although the theta/beta ratio was not high enough to clearly or exactly indicate the presence of ADHD with predominantly inattentive presentation, it is important to consider the full set of data provided by the MiniQ. It is also important to note that the diagnosis of ADHD was reported by the neuropediatrician, who usually uses behavioral criteria. At the same time, we cannot ignore the fact that the use of the theta/beta ratio has also been questioned by other works (e.g., [ 28 ]). In any case, the importance of the brainwave analysis lay in helping decide which intervention protocols to follow, along with the frequencies and the sites to use. The chosen neurofeedback protocols were the SMR protocol and the theta/beta protocol. There were 75 intervention sessions, 45 SMR at Cz and 30 theta/beta at Fz. Once the intervention was complete, the changes in theta, beta, beta3 and SMR waves were assessed using the MiniQ.

The intervention produced a variety of results. Firstly, there was a small reduction in theta activity and an increase in SMR, which would indicate better levels of attention. In addition, the theta/beta ratio fell to levels which were closer to those in subjects without ADHD. However, this improvement in the theta/beta ratio was due to increased beta rather than by the reduction of theta. Janssen et al. found similar results in 38 children with ADHD by analyzing the learning curve during 29 neurofeedback training sessions [ 29 ]. Their results indicated that while theta activity did not change over the course of the sessions, beta activity showed a linear increase during the study. In our study, the subject was able to significantly improve the levels of beta, but was hardly able to reduce theta activity, which is what would allow even greater improvements in attentional ability. Given this progress, the use of a protocol for inhibition of theta waves at Fz may be effective in strengthening the development of attention levels. Although there were no notable changes at other sites, such as F3 and F4, it is important to note that the intervention was carried out only at Cz and Fz.

On similar lines, during tasks after the intervention (reading and arithmetic), there was no reduction in theta but there was an increase in beta and beta3, again in line with the results from Janssen et al. [ 29 ]. For reading and arithmetic, one would expect, at least in subjects without ADHD, that in the frontal regions, values of slow waves would fall and fast waves would rise. However, in this study, there was no increase in beta waves in frontal regions during the tasks. This may indicate that although the neurofeedback intervention protocols in subjects with ADHD produce improvements in baseline activation (increased beta), the same does not happen with activation during the execution of tasks such as reading and arithmetic. In addition, Monastra et al. [ 7 ] showed that the activation profile of subjects with ADHD was similar with no task and during a reading task (unlike the control subjects, in whom activation increased during the reading task). Although this fact may be related to the ADHD profile, in our case study, with 75 neurofeedback sessions, we found no differences in the activation of frontal areas during a specific task, such as reading or mathematics.

As Enriquez-Geppert et al. [ 24 ] and Duric et al. [ 25 ] state, it is still necessary to develop specific procedures (which consider electrode placement and the specific theta/beta, SMR or slow cortical potential protocol) for intervention tailored to the different cases that professionals may find in clinical practice, in order to achieve better results. In this regard, it would be interesting to study theta/beta-ratio learning curves during intervention with neurofeedback, with the aim of achieving better results and making this tool as adaptive as possible in the future.

5. Conclusions

These results point toward the hypothesis that the low baseline cortical activation seen in subjects with ADHD would be found to be the basis of the disorder. While neurofeedback training may produce a positive progression, difficulties would persist, particularly during specific tasks in which subjects with ADHD are unable to achieve an ideal profile of brainwave activity for optimum performance. This is a reflection of the fact that the disorder persists throughout life, and hence, despite improvements in the cortical activation profile and the subject learning to strengthen their beta wave activity to concentrate, there will continue to be high levels of theta.

In this context, various studies such as Doppelmayr and Weber [ 30 ] and Vernon et al. [ 31 ] have reported the benefits of the SMR protocol and others, such as Arns et al. [ 13 ], Gevensleben et al. [ 32 ] and Leins et al. [ 33 ], have done the same with regard to the theta/beta protocol. However, other studies, such as Cortese et al. [ 34 ] and Logemann et al. [ 35 ], have not found improvements following neurofeedback intervention in children with ADHD. Considering these differences between previous studies, it would be interesting to establish the benefits of one or other of the protocols in interventions in children with ADHD. For example, in adults without ADHD symptoms, Doppelmayr and Weber [ 30 ] examined the efficacy of the theta/beta and SMR protocols. They found that the subjects who followed the SMR protocol were able to modulate their brain activity, whereas the theta/beta protocol did not provide benefits in regulation of brain activity.

It is also worth noting that, while previous studies employed similar protocols (SMR, theta/beta), the numbers of sessions and the session durations varied between studies. These variations may be related to the differences in the results and indicate the need to establish intervention protocols not only about what to work with (brain waves) but also how to do it (e.g., number of sessions, session duration, break schedules, etc.). At the same time, the present study underscores the need to tailor protocols to subjects’ profiles, along the same lines as previous studies, for instance Cueli et al. [ 16 ], who noted differences in the benefits of interventions based on the type of ADHD presentation. As authors such as Leins et al. [ 33 ] have indicated, most neurofeedback intervention programs combine two protocols, and it would be interesting to determine whether the combination is more effective than applying a single protocol.

In the future, it would be advisable to assess subjects’ levels of activation every 10 to 15 sessions of neurofeedback training in order to tailor the protocols to their progress and to study the theta/beta ratio learning curve as mentioned above. One limitation it is important to note is that multidomain assessments before, during, and after treatment (and adequate follow-up) should include blinding and sham inertness Another limitation of the present study is the lack of a behavioral assessment that would allow for an in-depth analysis of the subject’s progress in line with the protocol from Holtmann et al. [ 36 ]. At the same time, in spite of the limitations associated with case studies, such as not being able to produce generalizable results, the present work aims to be of some use to clinical and educational professionals so that they may consider intervention protocols for cases similar to the one described here.

Finally, despite the limitations described above, it would also be useful to consider the possibility of incorporating this type of training in more cases of subjects with ADHD, because neurofeedback intervention may offer long-term benefits in terms of improving the attentional abilities of subjects with ADHD, especially if one considers that approximately a third of ADHD patients do not respond to, or sufficiently tolerate, pharmacological treatment [ 37 ]. In this regard, it would be interesting to analyze the efficacy of new potential tools that combine neurofeedback and virtual reality and incorporate them into clinical practice [ 38 ].

Author Contributions

Conceptualization, P.C. and M.C.; methodology, all authors; formal analysis, M.C. and P.G.-C.; data curation, L.M.C. and P.G.-C.; writing—original draft preparation, P.C., M.C., and L.M.C.; writing—review and editing, P.G.-C.; visualization, P.C.; supervision M.C. and P.G.-C.; project administration, P.C. and P.G.-C.; funding acquisition, P.G.-C. All authors have read and agreed to the published version of the manuscript.

This study was made possible thanks to financing from the Ministry of Sciences and Innovation I + D + i project with reference PGC2018-097739-B-I00; and a pre-doctoral grant from the Severo Ochoa Program with reference BP19-022.

Institutional Review Board Statement

Ethical review and approval were waived for this study, because the study did not involve biological human experiment and patient data. The study was approved by the relevant Ethics Committee of the Principality of Asturias (reference: PMP/ICH/135/95; code: TDAH-Oviedo), and all procedures complied with relevant laws and institutional guidelines.

Informed Consent Statement

Informed consent was obtained from the family involved in this study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Adult Psychological Assessment Cases

Case summary.

Y.N. was a 27 years old lawyer who had completed his LLM and belonged to an upper middle socio-economic class. He came to the Center for Clinical Psychology with the complaints of excessive worrying and concern about his own health, family’s well being, business and future. The worrying was accompanied by headache, fatigue, restlessness and disturbance in personal and social life. He was assessed through a clinical and diagnostic interview, mental status examination, GADS-7, Metacognitions Questionnaire and DSM-5 checklist. The client was diagnosed with Generalized Anxiety Disorder and the management of his symptoms was done according to the techniques of Cognitive Behavior Therapy. The techniques used during his management were psycho-education, guided questioning, suppression experiments, questioning the evidence and mechanism of negatively associated meta-beliefs, dissonance techniques and relaxation exercises. The comparison between pre and post assessment revealed improvement in the client’s symptoms and his overall functioning.

Age: 27 years

Gender: Male

Education: Currently enrolled in LL.M

No. of Siblings: 3

Birth order: Last born

Marital Status: Single

Occupation: Lawyer

Religion: Islam

Informant: Client Himself

Reason and Source of Referral

The client came to Centre for Clinical Psychology with the complaints of excessive worrying and concern about his own health, family’s wellbeing, business and future. The worrying was accompanied by headache, fatigue, restlessness and disturbance in personal and social life. He was referred to the trainee clinical psychologist for the assessment and management of his symptoms.

Presenting Complaints

Table 1: Presenting Complaints as Reported by the Client

History of Present Illness

The client’s problems started 5 years ago (2012) when his father suddenly passed away in a road accident. He was out of station at that time and got the news over the phone. He was devastated by the tragic news and went straight to home. Seeing the dead body and the funeral process was distressing for the client. It was difficult for him to cope with the situation as he was deeply attached to his father. Being the youngest child he received extra love and attention from his parents making him dependent on them. The loss shook the client completely and it took him almost 2-3 months to recover from it. He became close to his mother, did not leave his house and was least interested in his studies. Due to this his grades in the 1 st year of his bachelors also declined. After 2 months of his father’s death, the client went back to the city where he was studying. He continued to take classes but could not keep concentration during them. He kept on thinking about his father, his loss and how helpless he was. His grades continued to decline in the second year as well. The client’s friends helped him recover through the process. He had a friend who also lost his father in early adulthood so the client paired with him and sought necessary advice from him. It took the client a year to recover from the loss although he still continued to miss him but he learned to function in a better way by accepting the harsh realities of life.

The client’s remaining 2 years of LLB went smoothly when in the last month of the degree, his brothers asked him to come back to his hometown and help his brothers in the business. The client was not interested in going back or becoming partners in the family business and refused his brothers politely. He took admission in LLM but his mental health deteriorated as he started to ponder upon future issues that he will not be able to handle the business or if his brothers would meet with an accident. He rejected the marriage proposal of his cousin as he did not feel like taking responsibility of anyone else. The constant worries made him sleepless at night and consequently performing inadequately in the day time. He would occasionally skip going to the court, rather stayed in his room lying down or reading the newspaper.

When the client shared his problems with his friends, they asked him to see a doctor. He visited a nearby hospital where the doctor recommended him to take the medicine ‘Alp’. The anxiolytic decreased his worrisome thoughts and increased his quality of sleep for 3 months after which the client discontinued the medicines as he did not want to get dependent on medicines. The client sought treatment from a psychiatrist who recommended him to consult a psychologist. He then came to the Centre for Clinical Psychology with the presenting complaints to get his symptoms treated.

The client did not report any sexual, physical or emotional abuse. No history of drug abuse, drug dependence, brain injury or accident was reported. Medical reports were also clear.

Background History

Family history.

Father. Client’s father died at the age of 64 years in a road accident. He was diagnosed with diabetes and minor kidney problems. He was a short-tempered person but had immense love and care for the family. He always gave time to his wife and children and maintained a healthy bond with all of them. All of the client’s family members used to discuss their problems with his father as he used to give appropriate and expert advice. The client also had a nourishing relationship with his father who always gave the client extra attention as he was the youngest child. His father’s death was a great loss for the client and it took him almost 2 years to recover from the tragedy.

Mother . The client’s mother was a 59 years old housewife whose health greatly deteriorated after her husband’s death. She was diagnosed with hypertension, diabetes and arthritis in the past 4 years. The client became more attached to his mother after the death of his father. He felt an obligation towards his mother so called her every day, talking to her for at least 15-20 minutes. He reported that he did not like staying away from his mother but had to do it because of his job.

The client’s parents had a commendable relationship between them. Both of them had mutual agreement and understanding between them which helped them to raise their children easily.

First born brother. The client’s brother was 37 years old, married and running the family business along with the second brother. He was physically and mentally fit. According to the client he was now the father figure in the house. The client had a cheerful childhood with him. He sometimes had arguments with him on business matters but they were resolved constructively.

Second born brother. The client’s second brother was 34 years old, married man and was also involved in the family business. He was a quiet person who remained calm and composed. The client sought advice from him as they felt close to each other. There were seldom fights. Their relationship was respectful and enjoyable since the childhood and the client valued his brother a lot.

Third born sister . The client’s sister was 30 years old. She was married and was living in her home happily. She had 2 children. She was loved by her parents and her brothers and so had a loving relationship with the client as well. The client was extremely attached to her sister’s children.

Fourth born was client himself. 

            General Home Atmosphere. The dominant person in the client’s house was his father but after his father his elder brother took control. All family members cared for each other and sought advice from each other. The family business was the source of earning for the entire family. There were less arguments or fights.

Personal History

Birth and Childhood History. The client was born through normal delivery but did not remember any of the other information about his birth or early childhood. He recalled that he had pleasant memories of his family when he played with his brothers. He had a stimulating and nourishing childhood and received love and care from everyone. No neurotic traits were reported.

Educational History . The client started his education at the age of 6 years. He went to the same school as his brothers. He sought guidance from both of his elder brothers who also took care of him in the school. He had satisfactory relationship with the teachers and usually scored average marks. He made many friends with whom he used to play during the recess time and hangout after school timings. He passed his matriculation and Intermediate through the same school acquiring 70% marks in Matric while 79% marks in Intermediate. For his graduate degree he had to move to another city where he adjusted well but the death of his father in the first year caused his grades to decline significantly. During the bachelors he remained disturbed throughout but still managed to pass through all the exams. His teachers considered him a below average student and occasionally warned him for his attendance. He completed his bachelors and applied for masters in the same university. He was enrolled in the Masters program since one year and was managing to do his job and studies together.

Pubertal and Sexual History. The client achieved puberty at 15 years of age. He gained weight, his beard started growing and he experienced nocturnal ejaculations. He reported that he masturbated sometimes (approx. 2-3 times a month). The act was not distressing for the client.

Occupational History. He got employed after the completion of his bachelors degree. He reported that it was a strenuous job as the clients in the court usually pressurized him and his colleagues to take their case or charge less money. He still was interested in his job but felt lethargic due to insomnia. He had satisfactory relationship with his colleagues and seniors. The financial status of the job was also satisfactory for the client.

Pre-morbid Personality. The client was a cheerful and calm person before his symptoms emerged. He had lesser worries and he felt secure about his life. He met with people and his daily functioning was adequate. His thoughts were usually occupied by achieving his goals and becoming a successful lawyer. He had high frustration tolerance neither did he get irritated easily. He had good impulse control and also maintained his social relationships.

Psychological Assessment

The client was assessed on the basis of informal and formal testing.

Informal Assessment

Informal assessment comprised the following procedures.

• Clinical Interview

The client was first asked to sign an informed consent to ensure that he was willingly taking the therapy and all information he gave was his own choice. He was interviewed to elicit information about his bio-data, presenting complaints, their durations, intensities and frequencies. He was also probed about his childhood history, family history, personal life and occupational functioning.  Details regarding his symptoms helped to understand their development and the client’s coping strategies to handle the stress.

Mental Status Examination

The client appeared to be in his early adulthood. He was a slightly short-heighted and bulky man. He had freckles over his face while his forehead had distinctly developed lines due to constant frowning. He was wearing ironed and neatly kept clothes. He sat in a hunched posture at the edge of the chair. His mood was euthymic. His rate of speech was fast and tone was loud. Adequate eye contact was maintained. His mood and affect appeared to be pleasant. His motor behaviors including gait, posture and gestures were appropriate. The client preferred to perform activities up to perfection but did not have any obsessions or compulsions. His abstract thinking and judgment was adequate. He was well oriented in time, place and person. He had fair insight about his problems.

Visual Analogue (Subjective Ratings)

The client was asked to rate his symptoms on 0-10 (0 = being the least problematic, 10 = most problematic) scale based on the severity and degree of problem each symptom was producing. The ratings also clarified that what symptoms had to be dealt first according to the client.

Table 2: Subjective Ratings of Symptoms According to the Client

  Worry Thought Record

The client was asked to maintain a worry thought record which helped in obtaining information about the content of worry, duration and maintaining factors regarding his worrisome thoughts. It also helped to bring into awareness his meta-worries and apply reattribution during the treatment.  The client was compliant in filling the record form while clarifications were elicited during the sessions.

Quantitative Analysis

Table 3: Frequency and Duration of Thoughts and Intensity of Emotions of the Patient

Qualitative Analysis

Table 4: Different Areas of Worry Thought Record and Patient’s Responses on Them

Formal Assessment

The client was formally assessed on the following scale.

Generalized Anxiety Disorder Scale (GADS-7)

The Generalized Anxiety Disorder Scale is used as a screening tool and severity measure for GAD. The scale assesses mood and somatic symptoms related to worry, control behaviors to stop worrying and Type I worry.

Table 5: Raw score and Severity of Problems as assessed by GADS-7

The client’s score on the scale shows a high probability of having GAD. He was unable to control his worrisome thoughts which related to the assumption that something bad will happen. His scores on individual items also indicate that he was highly restless and felt keyed up most of the time during the day. The worry and its consequences were affecting his functioning severely in daily life activities as well.

Metacognitions Questionnaire

The metacognitions questionnaire is a self-report scale assessing different dimensions of metacognitive beliefs (beliefs about thinking). The scale is based on the metacognitive model given by Wells (1997). The test was administered to determine the degree of metacognitions the client was indulged in and what constituted her meta-worry. It helped in gaining more insight in the client’s worry about worry.

Table 6: Raw scores on Various Sub-scales Obtained by the Client on the Metacognitions Questionnaire

The scores show that the client had both positive and negative beliefs about worry that maintained his habit of worrying but also caused him distress. He was also worried about the consequences of worrying constantly and thought that he may become sick because of them. The negative apprehensions and judgments constituted his worry and meta-worry.

DSM-5 Symptom Elicitation Checklist

The DSM-5 checklist for Generalized Anxiety Disorder (GAD) was used to validate the presence of symptoms in the client. The questions were directly asked from the client in order to probe more symptoms which he had previously not reported. The client fulfilled the first criteria of the disorder as he had been excessively apprehensive and worrisome about the future, business matters, family’s health, his own health, his responsibilities etc.. The second criteria was also confirmed as the client was unable to control his worry which made him employ control behaviors such as sleeping, talking to someone, seeking reassurance or calling home. The client also presented with restlessness, fatigue, insomnia, disturbed sleep, muscular tension and difficulty in maintaining concentration which met the third criterion of the disorder. All the symptoms produced discomfort in the client’s daily life and hence disturbed her everyday functioning which confirmed his diagnosis of GAD.

• (F41.1). Generalized Anxiety Disorder

Case Formulation

The client was a 27 years old man concerned about excessive worrying about his family, future,    job and everyday issues. He was experiencing fatigue, insomnia, muscular tension due to constant worrying for which he sought clinical advice. The Diagnostic Statistical Manual 5 proposes through its research that the disorder is more prevalent in individuals aged above 30 years. For middle adulthood, the major concerns of individuals with this disorder are health related concerns of family and self, finances and misfortune of children. The researches validate the client’s concern about his own health, his family members’ well-being, business matters and future (APA, 2013). The client was also near the median age of onset of the disorder, as per the manual, which makes him more prone towards having the disorder.

Beck (1985) states that people hold assumptions about dangerousness and make these assumptions after some negative life events. They become fearful of unknown. They also pay close attention to the threatening cues. This correlates with the present client as he started to face problems after the death of his father. His father’s death was a negative and traumatic event for him which may have triggered excessive worrying and anticipation of more negative life events in his life.

Kendler, Hettema and Butera (2003) propose through their research that individuals who have experienced deaths, multiple episodes of loss and separation from near relatives have a higher probability of developing Generalized Anxiety Disorder. These individuals usually anticipate similar life events in the future and thus become more prone towards the symptoms of excessive worrying, remaining tensed and foreseeing negativity. In case of the client, he had experienced the death of his beloved father. Due to the past, he expected to lose someone in the future as well because of a death or a catastrophe.

Wells (1994a, 1995) distinguishes between Type I worry and Type II worry which is present specifically in clients with GAD. According to him, Type I worry concerns external daily events while Type II worry is basically worry about worry. The combination of the two types of worry and subsequent positive and negative beliefs about worrying together maintain the cycle of GAD and worsens the symptoms. Similarly, the client was also worried about daily life concerns compromising his Type I worry. But on the other hand he had both positive and negative beliefs about worry creating cognitive dissonance and thus anxiety in him. The constant back and forth movement of the client between Type I and II worry was being distressful and symptomatic for him.

Idiosyncratic Case Conceptualization (Wells, 1995)

Management Plan

Short-term goals.

Long Term Goals

• Continuation of short-term goals

Follow-Up sessions

Session Reports/ Management Plan

Session no.1                                                 time of session: 45 minutes, session agenda.

Develop therapeutic alliance, History taking, Mental Status Examination, Symptom elicitation and subjective ratings

Informed Consent and History taking

Rationale: To gather information about the client’s past life, and development of symptoms. Procedure: Informed consent was obtained to ensure that the client was willingly taking the therapy and providing information. The interview was held with the client to elicit information relevant to his current and past life. Interview consisted of both open-ended and close-ended questions. The client reported the information without hesitation. It was made sure that the client was comfortable while sharing his issues and all sensitive issues were discussed with care. Outcome:   The interview was helpful in producing detailed information about identifying data, personal life, education, sexual history, pre-morbid personality and history of present illness. It gave in-depth clarification about client’s symptoms, duration and frequency of symptoms, etiological factors as well as the maintaining factors. History was elicited to gain knowledge about the client’s daily life functioning before and after the emergence of symptoms. Family history was elicited to identify the support system for the client.

Rationale: To assess the client in multiple areas of functioning. Procedure: Some of the information was gathered by observing the client’s behavior, actions and speech while others were directly asked from the client. Outcome: The client had appropriate behavioral functioning except the presence of a pre-occupation with his bodily symptoms and reactions.

Symptoms Elicitation and Subjective Rating

Rationale : To get a clearer picture of the client’s symptoms and his own rating about each symptom. Procedure: The client was asked to rate his symptom on a scale of 0-10 where 0 was least problematic and 10 was the most. Outcome: The client prioritized his symptoms according to their severity which helped in determining which symptoms were to be dealt first.

Therapeutic Alliance

Rationale: To bring both the therapist and client at ease and on good terms, trust each other, be open towards one another and show respect. The alliance is necessary to create a sense of understanding, confidentiality and regard between both individuals so that blocks and hesitance can be avoided. Procedure: The therapist tried to build a professional yet empathetic relationship with the client to make him comfortable during the therapy. The therapist maintained a non-judgmental and concerned attitude towards the client’s issues. The client was allowed to give his own perspectives regarding the issue and tell all the information relevant to his symptoms. He sometimes had to be re-directed towards the major issues when he kept talking about minor irrelevant details. The client was also provided with the feeling that the therapist completely understood what he was going through and how the symptoms were affecting him negatively. The client was further engaged in therapy by asking about his family and personal history. Relevant information regarding the symptoms’ precipitating and maintaining factors were probed. Rapport was built by actively listening to the client and providing him with unconditional positive regard. Outcome: The client trusted the therapist and problems were discussed freely.

Homework given: Worry thought record was given to monitor the quantitative and qualitative aspects of the client’s worries.

Session No.2                                                Time of session: 45 minutes

Differential diagnoses, Formal assessment (Generalized Anxiety Disorder Scale and Metacognitions Questionnaire)

Homework review: The client’s worry thought record was reviewed. The content of worries and client’s reactions were seen.

Differential Diagnoses (American Psychological Association, 2013)

Rationale : To get a clearer picture of the client’s symptoms and rule out irrelevant diagnosis. Procedure: Symptoms specific to the disorder were asked. The cluster of anxiety disorders were thoroughly investigated to reach to a final diagnosis. Outcome: Normal worry, Major Depressive Disorder and Panic Disorder were ruled out and GAD was confirmed.

Formal assessment (Generalized Anxiety Disorder Scale-7)

Rationale: To elicit more information about the client’s symptoms using a standardized tool. Procedure: GADS-7 was a 7 item questionnaire which was explained to the client. He was told about how to answer the questions and how he was supposed to respond. He completed the questionnaire in 5 minutes and was easy for him. Outcome:   The scale was helpful in identifying the degree of worries client felt.

Formal assessment (Metacognitions Questionnaire)

Rationale: To elicit information regarding the client’s content of worries and how much they affected the client. Procedure: The procedure to attempt the questionnaire was explained to the client. He was given ample time to fill it. All ambiguities were removed. Client comfortably did the complete questionnaire in 30 minutes. Outcome:   The test was administered to determine the degree of metacognitions the client was indulged in and what constituted his meta-worry. It helped in gaining more insight in the client’s worry about worry. The scores show that the client had both positive and negative beliefs about worry that maintained his habit of worrying but also caused him distress. He was also worried about the consequences of worrying constantly and thought that he may become sick because of them. The negative apprehensions and judgments constituted his worry and meta-worry.

Session No.3                                       Time of session: 45 minutes

Psycho-education, socialization, advantages and disadvantages analysis of worrying, identification of control behaviors.

Review of previous session: The previous session was reviewed by summarizing the client’s symptoms and his performance on the questionnaires. This helped in bridging the gap between previously told symptoms and new information which was to be provided in the present session. The client diagnosis was also confirmed to him as he wanted to know if his symptoms were real.

Psycho-education (Wells, 1997)

Rationale: To orient the client towards his symptoms, their development, precipitating factors, treatment plan and prognosis.  Procedure: Psycho-education was conducted to address queries of the client about the illness i.e. what it is, why was it happening, what other symptoms could emerge, what should be the measures taken, are medicines necessary, what can be the psychological treatment plans, how long will the client take to recover and what is the probability of complete eliminations of symptoms. The information was provided under the light of recent researches and the psychiatric manual. The process of psycho-education was also accompanied by informing the client about what was required from him. The role of the therapist was clarified and client was told to help himself at maximum. Therapy protocol was discussed i.e. the no. of sessions, duration of sessions and expectations of the client from the therapist. Importance of homework assignments was also discussed. Outcome:   The client was convinced and relaxed after he was psycho-educated. He asked multiple questions about how the therapy will take place and for how long. His questions about the prolongation and healing of his symptoms were also addressed.

Socialization (Wells, 1997)

Rationale: To make the client understand the development and process of his disorder. Procedure: Wells (1997) emphasizes the importance of socializing the client with the model of GAD. According to him, selling the concept of meta-worry and the maintaining factors of worrying help the client to know what the actual problem is. In the socialization process, the client was told that his daily thinking circulates between type I and Type II worry which are strongly help by his positive meta-beliefs but also become problematic for him when negative meta-beliefs are activated. He was also told that it was not about the content of worry that is causing the issue but it is the act itself which is the challenge. The client agreed upon the cycle of worrying and understood it completely. He was then educated about the points at which therapy had to be employed and change had to be introduced. Outcome: The model had a great impact on the client as he felt that his symptoms were being understood and there was a solution for them. He understood the concept fairly well and took the model along with himself to review it again.

Advantages and Disadvantages analysis of worry (Wells, 1997)

Rationale: To identify the positive and negative beliefs the client had associated with worrying. Procedure: The analysis was carried out during the session by creating a double column and verbally eliciting information regarding his beliefs. The beliefs that made him carry on with worrying were put under his positive beliefs while the beliefs that made him distressful about his worrying were included in negative beliefs. Outcome: The procedure itself instilled slight insight in the client about his views regarding the thought processes. It also gave the client insight about beliefs of danger and appraisal of uncontrollability.

Identification of control behaviors (Wells, 1997)

Rationale: To identify the behaviors of client which he used to tackle with his worry. Procedure: It was done through verbal strategies by asking the client about his behaviors when he worried too much or felt irritable because of worrying. Initially, the client had to be briefed about the purpose of control behaviors, after which he successfully identified his control behaviors. The questions introduced his ways to deal with his stress or put a stop to his act of worrying. Outcome: The Control behaviors were identified so that they may be eliminated and the client can learn to deal with distress and worry through constructive procedures.

Homework given: The CBT model of GAD was given so that the client may review and understand it. He was also given a copy of the advantages and disadvantages analysis so that he can go through his verbatim again.

Session No.4                                                      Time of session: 45 minutes

Suppression experiments, guided questioning, What if experiment, Normalizing worry

Review of previous session: The client was inquired about any queries he had regarding the last session. Questions relating to his disorder were addressed again. CBT model was reviewed so the symptoms can be addressed again and therapy protocol may be continued.

Guided Questioning (Wells, 1997)

Rationale: To elicit the meaning, client attached to the act of worrying. Procedure: The method was used as the client was initially unable to tell if he was being worried by his worrying. He would reply with one sentence that he worries a lot but could not tell if he was being affected by worrying. Guided questioning helped in clarifying the client’s view about his act of worrying. Questions relating to Type I worry were asked from multiple perspectives which were helpful in identifying the Type II worries. Outcome: It helped to control the worry as the client understood the content well.

Suppression experiments (Blue-rabbit technique) (Wells, 1997)

Rationale : The experiment was used to make the client realize the paradoxical effects of controlling worry. Procedure: At first, the client was asked to close his eyes for 3 minutes and then try to think of a blue rabbit. Once the client was able to achieve it, now he was asked to close his eyes and try NOT to think of a blue rabbit. The rationale of the technique was kept hidden. He was then asked to open his eyes and tell if he was successful in doing the job. The client reported that all the time he was thinking of a blue rabbit although he had never even seen one. The purpose of the technique was then explained to the client that the worries rebound in the same manner as the image of the blue rabbit, whenever the client tries to control them. The more he wanted to get rid of the thoughts (suppress the thoughts), the more they come back in his mind. Outcome: The experiment was helpful in making the client understand the reason of his worrisome thoughts.

What-if experiments (Wells, 1997)

Rationale : To make the client understand the consequences of excessive worrying. Procedure: A situation was taken in which the client was asked to tell what he dreaded. The situation was taken further until the client had imagined worst possible consequences. At that point, the client was stopped and made to realize that excessively worrying about a matter always produced negative and worst possibilities in the mind, even if there was a least chance of that scenario to happen.  Outcome: The experiment had to be done in multiple sessions to convince the client. The client realized its validity after 2-3 experiments had been done. It proved to be effective.

Normalizing worry (Wells, 1997)

Rationale: The client had to be specifically educated about the difference between normal worry and pathological worry. Procedure: He was initially told that everyone in the world worries to some extent. All individuals have worries related to their education, children finances, home, job, relatives etc. But then he was explained the difference by putting the phenomenon of worrying on a continuum where at one end worrying was beneficial for the individual but on the other it was dangerous and problematic. He was educated that worry can be helpful up to a certain point but excessive worry leads to no positive outcomes, rather a continuously stressed brain. Outcome:   The normalization helped in making the client understand to create a balance in his worrying thoughts.

Homework: The client was asked to do the blue rabbit technique again at home. This was recommended so the client can be convinced that trying to waiver the thoughts may result ina rebound.

Session No.5                                 Time of session: 45 minutes

Verbal Reattribution (Questioning the evidence), Sleep hygiene

Homework Review: The client was asked if he practiced the blue rabbit technique at home and its effects. He told that he practiced it multiple times and each time he was not unable to NOT think about the blue rabbit. He was convinced that getting rid of the thoughts will end up in the thoughts coming again.

Verbal Reattribution (Questioning the evidence) (Wells, 1997)

Rationale : To question the client’s beliefs of going crazy because of excessive worrying. Procedure: The client had a belief that he would go crazy if he worried this much and that worrying to this extent was not normal. The increased meta-worried intensified his symptoms. In order to challenge his belief, the client was asked to list down the evidences he had in favor of getting mad or going crazy because of the thought. He was also asked to write the instances in which anybody he knew went crazy because of overthinking.  Outcome: The experiment helped in revealing that the client was holding his belief without any firm evidence or basis. It ensured the client that his belief was illogical and decreased client’s degree of belief in his thought.

Sleep hygiene tips

Rationale : To manage his sleep timings and measures he should take to have a better quality of sleep. Procedure: The client had a habit of lying down on his bed and keep on thinking about future events and possible negative outcomes. For this purpose, he was told to use the bed for sleeping purpose only and sit upright on a chair when he felt like thinking upon future issues. He was told that empirical studies and research proves that negative thinking is least intrusive when the individual is in an undesirable and uncomfortable posture, while they become more emotionally charged when the person thinks about them in relaxed positions. Another research was quoted that when a person lies in the bed worrying, he/she associates the bed with negative thinking. In response every time he/she uses the bed, she starts to think negatively. The research evidences were striking for the client and she agreed to use her bed only for sleeping purposes. All other activities were carried in their appropriate ways. Other than these, tips regarding healthy diet, sleeping hours and sleep timings were also given. Outcome: The instructions were clearly understood by the client

Homework: Sleep hygiene tips were given to be practiced at home. He was also asked to try to challenge his beliefs at home such as his belief that he will lose control or will be unable to handle his thought processes.

Session No.6                                                  Time of session: 45 minutes

Challenging uncontrollability of thoughts, worry time

Homework Review: He was asked about the improvement in his sleep. He told that his sleep was slightly better now and he was trying to implement all the tips on himself. Moreover, he was inquired if he tried to restructure his belief by questioning the evidences he had for them. He was able to modify the belief that he will lose control over himself as he did not have any strong evidence in favor of it.

Challenging Uncontrollability of thoughts (Wells, 1997)

Rationale : To make the client realize that his thoughts processes were in his control. Procedure: Initially, the client’s negative beliefs about worrying were modified. He was asked about the times he could switch her worrying ON or OFF. The client replied that he could not control her worrying besides trying. He was then questioned about the times he distracted himself or got himself busy in other mental activities. It was those times when he could switch OFF his worrying thoughts. Outcome: The client realized about his own controlling behaviors after the facilitation of the therapist and was convinced that worrying can indeed be controlled.

Rationale : To make the client focus on his worries and thoughts only once a day and also to strengthen his belief that worrying or not worrying was in his control. Procedure: He was asked to specify a certain time of day in which he will worry about the problems and then find suitable solutions for them. At the other times of day, when he worried about daily problems, he was asked to postpone the worry until the worry time and then utilize that time for constructive work. Outcome: The controlled worry periods also helped to loosen the client’s belief that worrying itself is uncontrollable.

Homework: The client was asked to practice worry time at home as well as convince himself that the worrying was under his control and he can lessening his degree of worrying if he wants to.

Session No.7                                 Time of session: 45 minutes

Verbal Reattribution (Questioning the mechanism), Progressive Muscle Relaxation

Previous session and Homework Review: The client practiced worry time at home. He gave the feedback that he was unable to worry in the specified time as well. He was successful in postponing worry and also in lessening it.

Verbal Reattribution (Questioning the mechanism) (Wells, 1997)

Rationale : To make the client realize that his thoughts were illogical and not based on true processes. Procedure: He was asked about the procedure through which one goes crazy. The client could not recall any known person that had gone crazy due to worrying. Outcome: The client was then briefed that the process of going crazy or acquiring a severe condition was different rather than only due to worrying. He was convinced that his beliefs were not based on facts rather on assumptions he made himself.

Progressive Muscle Relaxation

Rationale : To relieve the client’s fatigue and muscular tension. Procedure: The client was told to practice at least 2 times during the day to attain maximum relief from somatic symptoms. The muscles of forehead, neck and shoulders were emphasized during the relaxation exercise so that he felt the difference between the tensed and relaxed muscles of the body. Outcome: The relaxation exercise was adequately understood by the client and he planned to carry it out daily.

Homework: Instructions for muscle relaxation technique were given to the client so he may follow them at home. He was also asked to monitor his thoughts and check if they were realistic or not.

Session No.8                                  Time of session: 45 minutes

Problem-solving cycle, distraction techniques

Homework Review: The client practiced  the relaxation exercise at home and reported that it created a significant difference in his muscular tension and that it was a physically and mentally relaxing time for him.

Problem solving cycle

Rationale : To make the client constructively find solutions for his issues, problem-solving cycle was explained to him. Procedure: The cycle was described by incorporating examples of the client’s life. The steps included identifying the problem on which he worried, finding all possible solutions and then selecting the most plausible and beneficial solution. Through the cycle, the client was told about the appropriate and worry-free resolution of the problem and that worrying alone did not result in finding any kind of solution. It educated the client about the step at which he selected the problem and after which worrying will not be beneficial in any way and so the cycle puts an end to worrying. Outcome: The client understood the cycle, but found it difficult to implement for every small worry. He tried to apply it in maximum issues as possible.

Distraction techniques

Rationale: To manage client’s worry when he found it unable to stall it. Procedure: The times when he found it difficult to stop worrying, he was asked to engage in other mental activities such as talking to someone, reading a magazine, watching television, going out with friends etc. Outcome: Distraction was effective in controlling client’s worrying and further helped him to reduce the duration of worry.

Homework: The client was suggested to follow the problem-solving cycle at home and use it for every possible problem. He was also suggested that the problem-solving cycle will help him in handling difficult situation with more efficiency.

Session No.9                                             Time of session: 45 minutes

Therapy blueprint, post assessment

Homework Review: The client implemented the problem-solving cycle in various issues and reported that it helped him to worry to a certain extent after which he left it when he found no solutions to the problem.

Relapse Prevention and Therapy Blueprint

Rationale: To aid the client in future situations, in case of any relapse. Procedure: After the client was gone through all the techniques and he had practiced them at home, he was again explained all the techniques in one session and how it had helped him in dealing with the symptoms. He was given a therapy blueprint which summarized the major techniques done, situations in which that technique could be applied and its procedure.

Post-assessment

Visual analogue.

Subjective Ratings of Symptoms According to the Patient

  Generalized Anxiety Disorder Scale (GADS-7)

Raw score and Severity of Problems as assessed by GADS-7 at a pre-treatment and post-treatment level

Meta-Cognitions Questionnaire

Raw scores on Various Sub-scales Obtained by the Patient on the Metacognitions Questionnaire

References;

• American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders.  Fourth Edition, Revised
• Comer, R.J. (2006). Abnormal Psychology, (6 th ed.). Princeton University, US
• Kendler, K. S., Hettema, J. M., Butera, F., Gardner, C. O., & Prescott, C. A. (2003). Life event dimensions of loss, humiliation, entrapment, and danger in the prediction of Onsets of Major Depression and generalized anxiety. Archives of General Psychiatry , 60 (8), 789. doi:10.1001/archpsyc.60.8.789
• Wells, A. (2013). Cognitive therapy of anxiety disorders: A practice manual and conceptual guide . John Wiley & Sons.

The client was a 27 years old man educated up to MBA and working as an assistant officer in a a bank. He belonged to an upper middle class family. He came to the Centre for Clinical Psychology to seek treatment for his symptoms of increase heart rate, palpitations, dizziness, lightheadedness, fatigue, feeling of choking, bloated stomach, high blood pressure, fear of dying and a preoccupation of having future panic attacks since a period of 2 months. He was assessed through a clinical and diagnostic interview, panic diary, visual analogue and panic rating scale. After detailed assessment he was diagnosed with Panic disorder. His treatment plan included in-depth psycho-education, behavioral and verbal reattribution, cognitive restructuring, coping statements and relaxation exercises. The treatment was helpful in subsiding the client’s symptoms as evident by the discrepancy between pre and post assessment.

No. of siblings: 3

Birth Order: 2 nd

Education: MBA

Occupation: Assistant Officer in Bank

Marital Status: Unmarried

Informant: Client himself and his mother

Reason and Source for Referral

The client came to the Centre for Clinical Psychology upon the recommendation of his sister. He complained of increased heart rate, palpitations, dizziness, lightheadedness, fatigue, feeling of choking, bloated stomach, high blood pressure, fear of dying and a preoccupation of having future panic attacks. He was referred to a trainee clinical psychologist for the assessment and management of his symptoms

Table 1: Presenting Complaints of the Client as Reported by Him.

            The client started to experience the above stated symptoms 2 months back when he experienced a major stressful event in his life. Before the event, the client rarely presented with any of the issues he reported. The client was living in Dubai and in March 2017, he went on a trip with his friends where he met with a deadly prank during night time. He was present in a car with three of his friends and they were going on an empty road. Two of the friends in the car knew about the prank while the client and one of his other friends did not know what was about to happen. The prank was initiated by acting out that the car had broken down and all the members had to leave the car. The client also did as said but after leaving the car they were suddenly chased by a guerilla. The guerilla was actually their friend dressed in a costume. The client and his other friend ran for their lives but could not find help or shelter. They were threatened by the guerilla for almost an hour while the prank took almost 3 hours to finish. It became a life-threatening event for the client while he tried to save his life for the most difficult 3 hours of his life. After considerable time had lapsed, the client and his friend were rescued by the other friends where they were told that they had been pranked. Initially the client was irritated by the whole event but eventually they all laughed it out. At the same night, the client experienced increased heart rate, sweating, palpitations, numbness and dizziness for the first time. He went to his uncle in whose house he was staying and asked him to check his blood pressure. The client’s blood pressure was high for which his uncle recommended him to drink plenty of water and try to sleep. The client was able to sleep after half an hour and woke up fresh in the next morning. After a few days the client visited the place again, where he was pranked for his satisfaction. He roamed around the whole place and felt content that nothing had happened. According to him, he wanted to pack-up the episode without getting affected from it anymore.

Besides the client’s efforts of forgetting the prank, he experienced the same symptoms after a week for which he consulted a cardiologist. He suspected a heart condition so got his ECG and blood tests done. The tests were clear but the doctor prescribed him with an anxiolytic (Indral 0.5 mg). The client started taking the medicine but read about its side effects on the Internet and thus decided to wear it off slowly.

The client started to experience his symptoms repeatedly (increased heartbeat and feeling bloated after eating, sweating while sitting in the office, dizziness while going to sleep) after one week and they increased to 3-4 times a week which made the client hypervigilant towards his problems. He feared that he would have a heart attack or would die due to his symptoms. Due to the constant concern he started to surf the Internet to know more about his problems. The websites provided him with loaded psychological words such panic attacks and depression and he diagnosed himself with Panic disorder. Since then he became more concerned about his symptoms, finding treatments on the Internet and also calling his family in Pakistan. He started to avoid the situations where he experienced the attacks which slowly started to disturb his occupational functioning. Leaving repeatedly and being constantly vigilant about his bodily symptoms made him less attentive towards his work. He started to keep a water bottle with him to use in the time of these attacks.  He consulted a general physician 3 times and got his blood tests and EKG done. The reports were normal and doctors told him that there was nothing to be worried out. The symptoms were still evident which made him and his family tensed about the situation so they decided to consult a psychologist.

The client came to Pakistan in May 2017, where his sister recommended him to get guidance from a psychologist. Hence, he came to the Centre for Clinical Psychology to seek assessment and treatment. He reported no history of physical or sexual abuse or use of any illicit drugs.

Father. The client’s father was a 61 years old, retired WAPDA official. He was in good health and was a calm-natured person. He did not suffer from any psychological illness. He once experienced heart symptoms but recovered in a month after seeking treatment and taking medications. His relationship with his children was congenial. He was involved with them and took care of their needs. His relationship with the client as well was satisfactory where both of them loved each other and discussed matters cooperatively.

Mother. The client’s mother was in her fifties and was working as a principal in a well-reputed school. She did not have any medical or psychological illness. She was a composed lady who worked hard to raise her children. She dedicated her time for the appropriate upbringing of her children. Her relationship with the client was also congenial as the client discussed most of his issues with his mother. She was the first person to know about the client’s symptoms. She remained concerned about the client as he was far and contacted him occasionally to keep in touch with him. They talked to each other almost daily through calls.

First born Sister. The client’s sister was 29 years old who had done her MPhil in Environmental Sciences. She was currently employed and unmarried. She had a friendly nature and also was strongly attached to the client. She reported that her brother had grown a little distant after he moved abroad but they still talked frequently and had frankness between them. The client also readily discussed his matters with his sister. They cared for each other and provided themselves if the other needed help.

Second born was client himself

Third Born brother. The client’s brother was 23 years old and currently enrolled in the last year of BBA. He was a social and outgoing boy. He enjoyed with the client a lot and also missed him after the client shifted. The client felt attaches to his brother and also provided him with the relevant guidance in studies and other matters of life. They talked over video calls and through texts occasionally. The client’s brother took the client as a role model to follow.

Fourth born brother. The client’s younger brother was 19 years old and in the first year if BBA. He was also a cheerful and fun loving person. He was an obedient son who showed respect towards the client. Both of them had a strong bond between them and played cricket and indoor games with each other whenever they met. The client had a nourishing and fatherly attitude with his younger brother keeping them bonded with each other.

            Birth and Childhood History. The client was born after a complete gestation period of 9 months and through a normal delivery. He had normal birth weight and color. He achieved his developmental milestones at appropriate time but started to walk slightly earlier. He had a nourishing and playful childhood when he used to play with his sister, cousins and neighbors. He was a cheerful boy who adjusted easily with strangers. No neurotic trait was reported by the client.

Educational History. The client started his education at the age of 6 years. He was an average student throughout his educational life. His primary education was rich with knowledge and he was an eager child to go to school. His teachers never complained of him rather appreciated him in all parent- teacher meetings. No incidences of bullying were reported rather he was also good at sports. The client completed his matriculation with above average marks and got admission in the college of his own choice. His Intermediate also passed with average marks and a good image in the college. After Inter he decided to do BBA and got into a well-reputed university for graduation. He made many friends, was outgoing and also maintained his GPA in average lines. He completed his MBA from the same university and achieved above average marks due to his interest in the subject. The client and his sister both reported that the client was an easy going child especially in studies as he studied himself and consulted their mother for any kind of guidance.

Pubertal History. The client achieved puberty at approximately 15 years of age when he started to grow a beard, experienced changes in his genitals and his voice got heavier. He reported some instances of masturbation but told that he preferred to remain away from such acts. Homosexual or heterosexual experiences were not reported.

Occupational History. The client was working an assistant officer in a Bank situated in Dubai, UAE. He had been employed since one year and was content with his job. He reported that there were stressful times at work as well when the load of work increased and he had to work for more hours. He sometimes skipped his extracurricular activities due to work. He had satisfactory relationship with his employer and colleagues. He went out on trips and dinners with his friends and co-workers. He was social and did not face any major issues with his fellow employees. The client had been facing some problems due to his symptoms since the last 2 months at work as he avoided sitting in the office when his symptoms occurred or he would exit the room. He usually went to go for a walk or have a cool drink. He also took 3-4 half day leaves since his symptoms started to emerge. He did not discuss any of issues with his colleagues or boss as he decided to seek treatment on a personal level.

Hobbies/Interest. The client was athletic and enjoyed sports from his childhood. He played cricket while he was in Pakistan. After moving to Dubai, he was unable to continue playing cricket but indulged himself in swimming and gym activities. He regularly dedicated time to physical activities but reduced them after the symptoms started emerging.

Pre-morbid Personality. The client was social and outgoing before his symptoms started to show. He was eager to go on trips, have fun and feel energetic. He was confident and never felt more focused or attentive towards his health or body. He used to go for exercise, extracurricular activities (gym, swimming, outdoor games) and did not hesitate in physical exercises. Even at times of stress, the client used to act cool and calm because he took life problems as a challenge but nothing to stress about. He had a high frustration tolerance and less impulsivity. He took decisions steadfastly rather than remaining confused.

 Psychological Assessment

The client was psychologically assessed on informal and formal basis. Informal assessment included:

Panic Diary

Formal assessment comprised of:

Panic Rating Scale

Clinical and diagnostic interview.

Informed consent was obtained from the client and his mother to report all information willingly and to ensure that the client was taken therapy according to his consent. The interview was conducted with the client and his mother. The interview gave detailed information about identifying data, personal life, education, sexual history, pre-morbid personality and history of present illness. The interview was beneficial in obtaining information of client’s symptoms, duration and frequency of symptoms, etiological factors as well as the maintaining factors. History was elicited to gain knowledge about the client’s daily life functioning before and after the emergence of symptoms. Family history was elicited to identify the support system for the client. History was also validated from his mother who provided with more information about the client’s behavior. The interview as a whole provided information about the client’s current health and to devise a case formulation and a management plan.

The client was an average heighted young man appearing to be in his late twenties. He was well-groomed and wore clothing which was adequate according to the weather. The client kept on fidgeting with his hands and shaking his legs. He appeared to be anxious as he spoke in a loud tone and his rate of speech was fast. He maintained adequate eye contact and appeared to be attentive towards the therapist. His orientation of time, place and person was intact. He had adequate short-term and long-term memory. He had insight about the psychological nature of illness.

Visual Analogue (Subjective ratings)

The client was asked to rate each of his symptoms on a scale of 0 to 10 to get information about the level of disturbance each symptom was causing and what intensity it had for him. In the scale 0 meant that the symptom was least intrusive in his life while 10 meant that it was the most.

Table 2: Ratings of the Symptoms According to the Client

The panic diary was given to the client in order to analyze frequency and intensity of panic attacks, as well as triggering factors, bodily sensations, emotions and his misinterpretation of negative thoughts as well as coping strategies used. He was explained the whole chart and was asked to fill it after every attack he had. The client filled the chart cooperatively which clarified more aspects of the panic attack (see Appendix B).

Table 3: Areas of the Panic Diary and the Client’s Responses

Table 4: Areas of the Panic Diary and the Corresponding Client’s responses

The panic rating scale was administered to ensure the presence of panic attacks and related behaviors and physiological arousal of the client (Wells, 1997). It is a self-administered test consisting of 4 items which assess panic attacks from various dimensions.

Table 5: Item Analysis of the Panic Rating Scale

The scale shows that the client had five panic attacks in a week and was also inclined towards avoiding such situations. His coping strategies were mostly, controlling his breathing, using medications, repeatedly checking his pulse, and trying to be with someone for reassurance or immediate help. The thoughts accompanying and maintaining the client’s attacks were mostly that he may have a heart attack or a stroke and fear of suffocation.

300.01 (F41.0): Panic Disorder, unexpected panic attacks.

The client was a 27 years old young man complaining of increased heart beat, sweating, dizziness, lightheadedness, choking, bloated stomach, fear of dying or going crazy and remaining preoccupied of having another panic attack in the future. He was diagnosed with Panic Disorder because of the symptoms and etiological factors. The risk of developing a panic disorder also includes environmental disorders (American Psychiatric Association, 2013). These can be identifiable stressors in months before the first panic attack such as interpersonal difficulties, physical well-being and negative experiences. In the client’s case as well, he experienced a grave incidence which risked his life. The prank caused him to think that he was going to die due to a constant threat. This may have triggered his panic attacks and the symptoms that started to appear just after the incident.

Goldstein and Chambless (1978) proposed a learning theory that a fear of impending panic or other feared bodily sensations, labeled “fear of fear.” From this perspective, innocuous bodily sensations become classically conditioned to the aversive physiological arousal associated with panic attacks. Because these classically conditioned sensations could trigger an unwanted panic attack across situations, individuals avoid various situations out of fear that they would be unable to cope with their panic if it were to occur in that situation. In the client’s case, his heightened physiological sensations had become associated with exacerbated bodily symptoms which resulted in a panic attack.

In addition to the above theory, Goldstein and Chambless (1978) also give more cognitive elements as a part of their theory as they propose that individuals who experience a panic attack are hyper alert towards their bodily sensations and interpret them as a sign of upcoming panic attack. The client under therapy also presented with the same cognitions and behavior. He became excessively concerned about his heartbeat and breathing and attempted to check them after every 20-30 minutes. He would usually check his blood pressure by a sphygmomanometer or ask his uncle to check his pulse. The act of being hyper alert caused him to experience and notice his symptoms more as compared to if he ignored them.

Bouton, Mineka, & Barlow (2001) propose that Panic Disorder develops because exposures to panic attacks causes the conditioning of anxiety (and sometimes panic) to exteroceptive and interoceptive cues. This process is reflected in a variety of cognitive and behavioral phenomena but fundamentally involves emotional learning that is best accounted for by conditioning principles. Anxiety, an anticipatory emotional state that functions to prepare the individual for the next panic, is different from panic, an emotional state designed to deal with a traumatic event that is already in progress. However, the presence of conditioned anxiety potentiates the next panic, which begins the individual’s spiral into Panic Disorder. In the client’s case as well, his exposure to situations in which he experienced the heightened bodily symptoms became associated with the thinking pattern that he was going to have a panic attack. In future instances, the conditioned bodily symptoms, thus lead to the triggering effect of thoughts and misinterpretations, eventually leading to a panic attack.

According to the vicious cycle model of David Clark (1986) panic attacks result from catastrophic misinterpretations of bodily or mental events. The events are misinterpreted as a sign of immediate impending disaster such as a sign of having a heart attack or collapsing or going crazy. The vicious cycle contains three elements; emotional reactions, bodily sensations and thoughts about sensations (misinterpretation). These elements are linked in a sequence which follows a particular pattern which can begin with anyone of the elements. Misinterpretation of bodily sensations is associated with anxiety and anxiety becomes a precipitating factor for another panic attack. This could be correlated with the present case as palpitations were seen as a sign of heart attack. The misinterpretation caused anxiety and maintained the vicious cycle.

 Idiosyncratic Case Conceptualization (Clark, 1986)

The client’s symptoms were managed and treated under the lines of Cognitive Behavior Therapy.

Session No.1                                     Time of session: 45 minutes

History taking

Rationale: To take the client’s consent for therapy and gather information about the client’s past life, and development of symptoms. Procedure: The interview was held with the client and his mother. They were told to report the details. More relevant and in-depth information was probed by the therapist herself. An informed consent was also signed by the client to ensure he was willingly taking the therapy. Outcome:   The interview gave detailed information about identifying data, personal life, education, sexual history, pre-morbid personality and history of present illness. The interview was beneficial in obtaining information of client’s symptoms, duration and frequency of symptoms, etiological factors as well as the maintaining factors. History was elicited to gain knowledge about the client’s daily life functioning before and after the emergence of symptoms. Family history was elicited to identify the support system for the client. History was also validated from his mother who provided with more information about the client’s behavior. The interview as a whole provided information about the client’s current health.

Rationale: To assess the client’s functioning in multiple areas.. Procedure: Some of the information was gathered by observing the client’s behavior, actions and speech while others were directly asked from the client. Outcome: The client had appropriate behavioral functioning except the presence of a pre-occupation with his bodily symptoms and reactions.

Rationale: To bring both the therapist and client at ease and on good terms, trust each other, be open towards one another and show respect. The alliance is necessary to create a sense of understanding, confidentiality and regard between both individuals so that blocks and hesitance can be avoided. Procedure: The therapist, at first, introduced herself to the client and his care-giver after which they were allowed to explain their problems. The client was shown unconditional positive regard while he was telling about his beliefs and symptoms. Empathy was practiced to ensure that the therapist understood and cared for what problems the client was going through.  Reassurance was also provided in the initial session to develop a sense of concern toward the client. During the process, the client’s mother also discussed the problems openly providing with maximum information about the client. Interruptions were kept at minimum to ensure adequate flow of information towards the therapist. Outcome: The client trusted the therapist and problems were discussed freely.

Homework given: Panic diary was given to assess the frequency, duration, intensity, antecedents of panic attacks.

Session No.2                                           Time of session: 45 minutes

Continuation and completion of history, Differential diagnoses, formal assessment (Panic rating scale)

Homework review: The client’s panic diary was reviewed.

Continuation and Completion of history

Rationale: To obtain more detailed information about specific areas of client’s life.  Procedure: The client was asked to report more information which he may have missed in the last session. Moreover, the therapist also inquired more information which she previously could not ask. Outcome: Revisiting the history helped in filling the gaps and getting a more detailed analysis of the problems

Rationale : To get a clearer picture of the client’s symptoms and rule out irrelevant diagnosis. Procedure: Symptoms specific to the disorder were asked. The cluster of anxiety disorders were thoroughly investigated to reach to a final diagnosis. Outcome: PTSD and specific phobia were ruled out while Panic disorder was the most justified.

Formal assessment (Panic rating scale) (Wells, 1997)

Rationale: To confirm the presence of panic attacks and consequent coping strategies. Procedure: Panic rating scale was self-administered by the client in duration of 10 minutes. Outcome:   There was a high frequency of panic attacks experienced by the client and multiple coping strategies were employed by him to cope with the symptoms

Homework given: Panic diary was given again to be filled thoroughly.

Session No.3                                               Time of session: 45 minutes

Psycho-education, socialization, paired association task, body focus task

Review of previous session: The previous session was reviewed by summarizing the client’s symptoms and his performance on the questionnaires. This helped in bridging the gap between previously told symptoms and new information which was to be provided in the present session.

Homework review: Panic diary was reviewed. Clarifications were obtained for information that were vague.

Rationale: To orient the client towards his symptoms, their development, precipitating factors, treatment plan and prognosis.  Procedure: Psycho-education was conducted to address queries of the client about the illness i.e. what it is. why was it happening, what other symptoms could emerge, what should be the measures taken, are medicines necessary, what can be the psychological treatment plans, how long will the client take to recover and what is the probability of complete eliminations of symptoms. The information was provided under the light of recent researches and the diagnostic statistical manual. The process of psycho-education was also accompanied by informing the client about what was required from him. The role of the therapist was clarified and client was told to help himself at maximum. Therapy protocol was discussed i.e. the no. of sessions, duration of sessions and expectations of the client from the therapist. Importance of homework assignments was also discussed. Outcome: . It helped to broaden the insight if client regarding his symptoms.

Rationale: To make the client understand the development and process of his disorder. Procedure: The client was explained the CBT model of Panic disorder to make him know how the problems develop and form a vicious cycle. The precipitating and maintaining factors of panic attacks were also elaborated so that he would understand the dimensions of his problem and recognize the points of treatment. Idiosyncratic examples of bodily symptoms experienced by the client were illustrated during the session, interpretation, and avoidance behaviors were put into the model for more clarification. Outcome: The client was initially reluctant in accepting that exacerbation of his symptoms were due to his thinking patterns but the model was revised after reattribution strategies, and at that point he agreed with the model and understood it adequately

Paired association task (Wells, 1997)

Rationale : To orient the client towards the underlying mechanism of his cognitions. Procedure : It was executed in which he was given pair of words in which one minor symptom was associated with another extreme bodily condition, for example, increased heart rate with heart attack, inability to breathe with suffocation etc. The task was presented by asking the client to read the pair of words out loud without explaining the rationale. Within 10-15 seconds, the client had furrows on his forehead and was looking anxious. A whole minute of reading the pairs caused him to get more fearful and he started breathing heavily. The words were then removed and the client was asked what he interpreted from the activity. Outcome: He got some understanding of its purpose which was then further explained by the therapist. He was clarified that the more he misinterpreted his symptoms, more he was prone to exacerbate them. He clearly understood this technique that beliefs of catastrophe exacerbate anxiety.

Body-Focus Task (Wells, 1997)

Rationale: To elaborate the phenomenon of selective attention and misperception. Procedure: The client was asked to focus on the palm of his hand and in second time his face for 3 minutes. He was given a mirror and was asked to look closely to all aspects of his face or hand. After the time had elapsed he was asked about the things he noticed. His response showed that he had noticed more negative features on his face. This point was then taken by the therapist to explain to him how constant monitoring of oneself can cause distortions in perception and focus on unreal aspects of the situation. He was given his own example that when he repeatedly checked his pulse and heartbeat, he mostly misperceived them which made him more concerned. Outcome: The task was helpful in making the client understand the consequences of his behavior and how they contributed towards the vicious cycle of thinking and avoiding.

Homework given: To practice body-focus task again at home. Read and understand the CBT model in detail

Session No.4                                                                                       Time of session: 45 minutes

Psyho-education revised, Disconfirming client’s beliefs and reassurances, normalizing

Homework review: The client was asked if he felt convinced about overemphasis and selective attention. He reported that he did those tasks and noticed that the things which were focused more proved to have more negativity in them.

Psycho-education revised

Rationale: To relieve the client’s stress about duration of symptoms and treatment. Procedure: The client kept on asking how long the symptoms will take to subside. He was again educated about his own role in decreasing the symptoms and improving his health. The factors that contributed towards a better prognosis were discussed. The importance of treatment adherence was emphasized and role of medicines was also clarified. Outcome: The client felt relieved after hearing that the symptoms can also go away completely. He also agreed to work upon his health with dedication.

Disconfirmation of beliefs

Rationale: To decrease the client’s reliance on irrelevant material on the Internet and consider the doctor’s and therapist’s words more competent. Procedure: Many examples about information from the Internet that misled people were discussed and the authenticity of information present on online websites was explicitly explained. He was convinced that guidance given by professionals on a one-to-on e basis is more beneficial than random facts and figures on the Internet. Outcome: The client seemed convinced by the discussion and decided that he will not draw conclusions by reading information on the Internet.

Mini-survey (Wells, 1997)

Rationale: To normalize the client about the existence of same symptoms in all individuals. Procedure: The client was taken to 5 people who were interviewed if they felt some of the symptoms felt by the client himself. They were also asked about the situations in which they felt such symptoms and how they coped with them. The client was allowed to question the people in detail to remove any ambiguities. Outcome: He understood that people also experience the same symptoms either at different times or all at the same time but their reasoning and attributions are different from those of the client.

Homework given: To continue physical activities and keep a check on the other reasons those are causing physical symptoms to occur rather than the probability of worse health consequences.

Session No.5                                              Time of session: 45 minutes

Behavioral Reattribution tasks (Hyperventilation provocation task, Physical exercise)

Homework review: The client was asked about his progress in refraining from reassurance and how his family responded to the survey technique. He reported that all the members felt those symptoms but nothing happened to them neither did they stress over those signs.

Hyperventilation provocation task (Wells, 1997)

Rationale: To induce panicogenic sensations in the client which were then related to disconfirm client’s beliefs. Procedure: The client was asked to walk on the lines of the tiles and breathe heavily. The activities helped in inducing symptoms such as increased heartbeat, sweating and dizziness in the client. After 2 minutes of heavy breathing the client was asked about his beliefs. His beliefs were then challenged as he induced the symptoms himself and nothing further happened. Outcome: His previous beliefs of dying or getting a heart attack were thus disconfirmed.

Physical Exercise tasks (Wells, 1997)

Rationale: As the client used to avoid strenuous activities so his heartbeat would remain stable, physical exercise was done to disconfirm beliefs. Procedure: The task was introduced by making the client run up and down the stairs outside the session room where the environment was congested. The client repeatedly stopped in between as he thought that he would have a heart attack but he was made to do it for another minute. He checked his heartbeat and pulse from time to time but he was explained by the therapist how it is least likely to have a heart attack just on the basis of the present symptoms. Outcome: At the end he was convinced that he would not die and nothing would happen to him rather his symptoms had many other reasons.

Homework given: To continue doing some physical exercise and record the times he felt the symptoms but nothing further happened.

Session No.6                                              Time of session: 45 minutes

Verbal Reattribution (Education about adrenaline rush), Decreasing avoidance (Using metaphors)

Homework review: The client did some physical activity which he reported during the session. The activities were utilized to disconfirm the client’s beliefs.

Education about adrenaline rush (Wells, 1997)

Rationale: To educate the client regarding the multiple factors that may be attributed for his physical symptoms. To make him reattribute his symptoms to other, more relevant and plausible factors. Procedure: The client was told about the adrenaline rush in which there is increased hormonal flow when the individual gets excited. In addition, he was also told why heart rate increases during stress and how one could not get faint when the heart was beating faster. He was also given counterevidence from his own situations and then related with the empirical basis for more conceptual clarity. Outcome: The research based evidence proved to be a significant factor which reduced the client’s intensity of beliefs.

Decreasing avoidance behaviors (Wells, 1997)

Rationale: To make the client realize the consequences of his avoidance behaviors and how they were helping in strengthening the client’s beliefs. Procedure: The client was given multiple examples, analogies and metaphors which suggested that people who tend to avoid certain circumstances end up in a cycle where they are never exposed to counter evidences. The prophecy keeps on fulfilling itself rather than the disconfirmation of his/her belief. Outcome: He understood the irony in those examples and realized that until he would quit his avoidance behaviors he will never know what happens in those situations.

Homework given: The client was asked to restrict his avoidance behaviors such as drinking water, checking heartbeat, asking someone to check blood pressure rather stay in the situation and observe what happens.

Session No.7                                             Time of session: 45 minutes

Verbal Reattribution (Questioning the evidence/counter evidence and questioning the mechanism)

Homework review: The client was asked about the times he felt the symptoms and what other factors were responsible in causing them. He reported that many times he felt the symptoms after eating food or climbing the stairs or when he was watching a stressful video. His own observations helped in shaking his beliefs.

Questioning the evidence (Verbal Reattribution) (Wells, 1997)

Rationale: To make the client identify evidence and counter evidence of thought in order to disconfirm his beliefs. Procedure: The client was asked to write down the evidences he had that a panic attack would occur or that he would die because of his symptoms. He listed down his symptoms that made him think that he had a heart condition and it may prove fatal. On the other hand he listed down counter evidences for all the past times he experienced a panic attack but nothing happened and also about future events. Outcome: It was evident from the list that there was less evidence about a panic attack to occur or an accident to happen. This made the client realized that the probability of a panic attack to occur was majorly in his head rather than a fact.

Questioning the mechanism (Wells, 1997)

Rationale: To educate the client and bring into awareness the actual mechanisms of his fears and the discrepancy between actual and perceived threat. Procedure: He was first inquired if he knew how heart attack or fatal diseases were acquired and what mechanisms were operative in these conditions. After his reporting, he was briefed about the actual processes that were involved in making an individual prone towards heart conditions or medical diseases (genetic factors, dietary habits, abnormal blood tests etc.). Outcome: The technique was helpful in educating the client as he was eager to know the true reasons of such diseases and felt relieved that he had none.

Coping Cards

Rationale: To make the client give positive self-instructions and us them in the time of anxiety. Procedure: The client was given 5” by 5” cards on which coping statements such as ‘I am OK’,’ I am physically fit’, ‘I can handle the symptoms’, ‘The symptoms may be due to some other reasons’ were written. He was asked to keep the cards with him or attach near his working table so that he can use them whenever he experienced his symptoms. Outcome: The cards helped in reminding the techniques he had learnt in therapy and giving positive feedback to himself. They also helped the client to tackle anxious situation by staying in them rather than avoiding.

Homework given: He was asked to work on his cognitions whenever he thoughts about his symptoms or future panic attacks. He was asked to analyze evidences in his mind and disconfirm his beliefs by the techniques learnt during session.  Moreover the coping cards were also given to practice when he faced stressful situations.

Session No.8                                                   Time of session: 45 minutes

Relapse prevention, therapy blueprint, post-assessment

Homework review: The client reported that he used the strategies that were taught to him and they were helpful in subsiding the symptoms. Coping strategies were employed by the client by memorizing and using them during strenuous activity.

Table 6: Pre and Post-treatment Ratings of the Symptoms According to the Client

Table 7: Pre and Post assessment of the Panic Rating Scale

Outcome of therapy

There was a decline in client’s symptoms as assessed by the pre and post assessment. He reported that he was feeling better and his panic attacks were greatly reduced. He utilized the technique taught during therapy which helped him distinctly.

Limitations and Suggestions

The client had to leave for Dubai after his 8 th session hence more follow-up sessions could not be conducted. He was suggested to consult a psychologist for a follow-up session.

• Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A modern learning theory perspective on the etiology of panic disorder. Psychological review , 108 (1), 4.
• Clark DM. A cognitive approach to panic. Behav Res Ther 1986; 24 :461–70.
• Goldstein, A. J., & Chambless, D. L. (1978). A reanalysis of agoraphobia. Behavior Therapy , 9 (1), 47-59.
• Wells, A. and Papageorgiou, C. (2004). Depressive Rumination: Nature, Theory and Treatment. UK: John Wiley & Sons, Ltd.

            The client was a 40 year old woman, educated up to B.A. and belonged to lower middle socio economic status. The client was referred to the trainee clinical psychologist for the assessment and management of her symptoms. Her primary complaints included repetitive, intrusive thoughts and associated repetitive behaviors, anxiety due to thoughts and disturbance in personal and social life. She was informally assessed by a clinical and diagnostic interview, mental status examination, subjective ratings and baseline for obsessions and compulsions and Y-BOCS. Based on the history and assessment she was diagnosed with Obsessive Compulsive Disorder. Her management plan was devised on the basis of Cognitive Behavior therapy encompassing techniques such as socialization, questioning evidence and mechanism, survey method, cost-benefit analysis, exposure and response prevention and concentration exercises. The techniques and willingness of the client helped in eliminating the client’s symptoms to a considerable degree.

Age: 40 years

Gender: Female

Education: B.A.

No. of Siblings: 4 (2 sisters, 1 brother)

Birth order: Third born

Marital Status: Married

No. of Children: 4

Informant: Husband, Client Herself

The client came to the Centre for Clinical Psychology with the complaints of repetitive and intrusive thoughts of being dirty resulting in excessive hand washing, clothes, cleaning house floor and washrooms. The symptoms also included distress due to her cleanliness behaviors, frustration, low mood, decreased social interaction and disturbance in her personal and social life. She came to the Centre upon the recommendation of her husband’s friend. She was referred to a trainee clinical psychologist for the assessment and management of her symptoms.

Table 1: Complaints of Patient as reported by herself

  History of Present Illness

The client’s problems started to emerge after a disturbing event occurred in her life in 2014. The client and her family lived in an underdeveloped area where most of the houses were congested and close. Her own house was not built properly so she and her husband agreed to renovate the house. Her husband called upon 3 laborers who were allowed to do plumbing and improve the sanitary lines of the house. The client used to remain home while her husband went to work and all her children would go to school. During the time of renovation, she started noticing the activities of the laborers. The laborers would usually make the house floor dirty with cement, dirt and garbage. The client reported that they would also urinate in the same area as there wasn’t another washroom in the house. They ate with the same hands and in the same place. The dirt did not disturb the client as much as the uncleanliness (Na’paaki) caused by those laborers. She started commanding the laborers to keep the area tidy and do their work with cleanliness. The laborers usually did not comply with the client’s commands so the client herself started to clean the area every day after the laborers left. The client’s husband told her not to clean it as the house would get dirty again the next day, but she felt uneasy so went forward with her own decision. It was then that the client started forming linkages between what was dirty and what became dirty after contact.

From then on, I started noticing what was touching. I used to see that if a child went to a dirty place and then brought his feet on the clean floor, he would tell him to wash his feet. Then if someone came from there and sat on the sofa, she would clean the sofa

The laborers completed their work in approximately 2 weeks after which the client had to clean the house entirely on her own. She found feces in some places which made her extremely angry and upset. She still cleaned the house as properly as she could. It was after then that the client’s symptoms started to emerge. She never got satisfied with the hygiene conditions of the house. She washed the house floor numerously with multiple detergents and also started to make rules for her children to enter the house. She kept an extra pair of shoes outside the house for herself and bought soaps of different companies to keep in the lavatory.

Within a year (2015), the client’s problem exacerbated greatly. She washed her hands innumerably throughout the day and always remained doubtful if she had washed them. She asked children to keep themselves tidy and not to sit on the sofas or chairs if they had not changed their clothes. She made a separate place for her religious activities (Namaz and Quran).

In late 2015, the client’s daughter started menstruating which further increased the client’s symptoms. She would repeatedly tell her daughter to take bath, change clothes, not to sit on something higher rather on the floor and to keep herself away from others. She separated her daughter’s towels, cupboards during her menstruation days. She also washed her daughter’s clothes separately so that the other clothes may not get “Na-paak”. This made her relationship with her daughter distant and the client started to become angry and irritable more often. She noticed every move of her daughter and linked each move with the previous one. This made her think that where ever her daughter sat was then ‘Na-paak’ and she had to wash the place and clothes. Her frequency of washing clothes increased greatly. She started buying large packets of surf and detergents and washed clothes every day for up to 5-6 hours. She would herself change clothes repeatedly which increased up to 6-7 dresses a day in the following year.

In 2016, the client’s husband noticed changes in her behavior and attitude and saw that the client was becoming asocial. She stopped visiting her sister or her mother and did not leave the house except for something that was very important. She kept an ‘abaya’ which she wore whenever she went outside and changed it as soon as she came back to the house. The client started to remain indoors, did not dress up or get ready besides her husband’s wishes and tried to remain isolated from others. She spent most of her time washing clothes or dishes and keeping the house neat and tidy. The strenuous activity made the client tired after the whole day and she would experience frequent body aches.  She started to remain distressed about her health as she realized that she was pushing herself beyond the limit but could not control herself. She considered her husband strict so did not share her problems with him as well. She tried to perform all her duties but her health would occasionally put her down. She also felt helpless about her condition stating,

‘One of my sisters has cancer. When I see him taking medicine, I am jealous that he has the solution to his problems but I don’t have it.

The client’s husband became concerned about her health and sought advice from his colleagues at work. They recommended a psychiatrist and a psychologist but the client was reluctant to visit any doctor as she thought that there was no cure for it. After insistence of her husband, she decided to visit a psychiatrist in a nearby hospital who told her to see a psychologist. She then came to the Centre for Clinical Psychology with the complaints of repetitive and intrusive thoughts of being dirty resulting in excessive hand washing, clothes, cleaning house floor and washrooms. The symptoms also included distress due to her cleanliness behaviors, frustration, low mood, decreased social interaction and disturbance in her personal and social life.

Father . The client’s father died at the age of 63 years due to stroke. He was diagnosed with hypertension, diabetes and risk of cardiovascular diseases. He took his medicines regularly but still suffered from a fatal heart attack. He did not have any psychological problems. He was an extremely strict person, remained angry most of the time, was short-tempered, had few social interactions and remained to himself according to the client’s account. The client’s relationship with her father was distant as she never felt comfortable talking to him. Her father did not interact with any of his children from their childhood and used to remain busy in his work. He rarely expressed his love or care for the children. The client reported that she spent most of the childhood remaining scared from her father. Besides the uncongenial relationship, the client still felt sad on her father’s sudden death and occasionally missed and prayed for him.

Mother . The client’s mother was 68 years old suffering from a cataract and heart problems. She took anxiolytics to help her sleep but did not have any significant psychological issues. According to the client, her mother was also strict and had perfectionistic tendencies. The client had some attachment with her mother but still did not feel emotionally linked to her. Her childhood was also filled with her mother’s orders and restriction regarding leaving the house, meeting people, keeping oneself clean and religious obligations. Although the client learned a lot but she did not share her issues with her mother. She used to visit her mother once a week but since the client’s symptoms started appearing she distanced herself from everyone including her mother.

First born sister . The client’s sister was in her forties, was educated up to F.A. and was a housewife. She was married to her cousin and had a contented life. She had no physical or psychological ailment. She remained concerned about her mother’s health but was mostly involved with her family matters. Her relationship with her sister was satisfactory. Both of them used to visit each other occasionally before the client’s symptoms started to emerge. The relationship got distant after the client’s issues but they still talked through phone calls. They took care of each other since childhood and so the client felt more attached to her sister than to her mother.

Second born brother. The client’s brother was 43 years old, educated up to Masters and was a private shop owner in his residential area. He suffered from hypertension. He used to smoke sometimes. The client’s relationship with her brother was distant as he adopted the same attitude exhibited by his father. He was strict in attitude and had conservative opinions about women due to which the client did not feel comfortable while conversing with her brother. She still maintained healthy relationship with his wife by calling her and keeping in touch with their issues. She mentioned that her brother was present for her in the time of need.

Third born was the client herself.

Fourth born sister. The client’s younger sister was in her thirties, was married and a housewife. She had three children and was satisfied at home. She was suffering from breast cancer but was getting her treatment done through surgery and chemotherapy. According to the client, she was a cheerful person who sometimes remained concerned about her health and children but still was social and maintained satisfactory relationships with others. The client also enjoyed being with her but they met less as she resided out of the city. They had pleasant interactions whenever they met and also remained concerned about each other’s health.

General Home Atmosphere (before marriage). The client had an extremely strict atmosphere at home. Her father was the bread winner and dominating figure at that time. She belonged to a lower middle socio economic family. The children weren’t allowed to do what they wanted where girls usually helped their mother while boys sat with their father. The client’s mother also kept a stringent attitude with all her daughters making family bonding weak. The client usually remained quiet whenever she was at home and also restricted herself from talking with the family much. All the members of the family were religious and all religious activities were carried out with discipline and respect.

Birth and Childhood History. The client was born through normal delivery by a mid-wife at home. She had average weight at the time of birth and color was pink. There were no problems during pregnancy while the client was conceived. She achieved her developmental milestones at appropriate time. She was a quiet child but played frequently with her sisters. She received love and affection from her parents which gradually reduced when she entered adolescence due to the mindset of her parents. No neurotic traits were reported in the client’s childhood.

Educational History. The client started her education at the age of seven years. She was an above average student who liked going to school. She reported that she was punctual, social and obedient. She had satisfactory relationship with her teachers. She liked Urdu and Mathematics. Throughout her early education she remained a bright student. She passed her matriculation and intermediate with average marks as she had to do the house chores as well. Moreover, her father kept on pressurizing her to quit school and stay at home. Besides the pressure she insisted on going to university and so completed her B.A. in harsh home environment. She claimed that she missed her college and university life as she had made a lot of friends and felt independent when she was out of the house.

Pubertal History. The client achieved puberty at the age of 13 years. She was well-informed about the phenomenon by her mother before it occurred. She coped well with the changes and learned to handle it quickly. She told that her mother was specific in keeping body and house clean. The client and her sisters were extra cautious in handling their sanitary things. They had to be vigilant while going in front of the male members of the house and keeping it strictly confidential. The client handled the situation with ease and perfection besides the extensive pressure. She did not feel difficulty in maintaining cleanliness at that time.

Marital History. The client had been married since 18 years. She had an arrange marriage. Her husband was a 48 years old man who had done B. Ed. and was working as a clerk in a university. The initial years were difficult for the client as she tried to adjust with a person she barely knew. The couple had mutual understanding but the client had complaints from her husband for not giving enough time. Moreover, they also had financial issues as her husband was reluctant in giving money for house expenses. She informed that her husband had a dominant personality and so she remained submissive most of the time. Both of them still maintained a healthy bond having care, love and affection between them. Her husband remained concerned about the client’s health since the last one year. Since the symptoms emerged, the client also observed a change in his husband’s attitude and appreciated his concern. Both of them mutually decided their children’s future but her husband still had the veto power. The client’s husband sometimes showed frustration regarding her symptoms but on other times proved to be supportive as well.

The client had 4 children, 2 sons and 2 daughters. The eldest child was her son who was 17 years old and was studying in first year. The next two were her daughters. Her elder daughter was doing matriculation while the younger daughter was in 8 th class. The youngest child was her son who was still in primary class. The client remained pre-occupied in upbringing her children and fulfilling all her responsibilities. She cooked, cleaned and washed for them and also performed the duty of walking them to school. Since the symptoms emerged, the client’s remained angry most of the time. She scolded them and tried to discipline them to the maximum. Her daughters grew distant from her due to her constant correction and taunts. She still helped them in their studies and remained concerned about them. One of the primary complaints of the client from her children was that they did not maintain cleanliness in the house.

Sexual History. There were no reports of any homosexual or heterosexual experience of the client before marriage. She had a satisfactory sexual life with her husband. There was mutual consent in almost all interactions. The client reported that the interactions had lessened now as she tried to avoid them as she thought that the act will make her dirty. She remained worried constantly that her clothes will get dirty due to arousal. This made her avoid watching the television or sitting close to her husband. The fears made her distant from her husband and she started to remain indulged in religious practices. Even upon the insistence of her husband, she did not get ready or dress up for her husband rather tried to remain physically away from him.

Pre-morbid Personality. Even though the client had calm and quiet personality before her symptoms emerged, she was still a social and content person. She used to meet with her relatives frequently, arranging meet-ups at her mother’s house and sitting in gatherings. She responded to stress calmly and with maturity. She had high religious inclination and maintained her social relationships. Her self-esteem and confidence was low.

The assessment was carried out on an informal basis upon the following lines:

• Baseline for obsessions and compulsions

Initially, the client was briefed about confidentiality and therapeutic process. Consent form was signed by the client, which was followed by a detailed clinical interview with the client and her husband. All information was corroborated amongst the informants. The clinical interview comprised of information regarding the client’s familial life, personal history, pre-morbid personality etc. The interview process also included the elicitation of symptoms, their frequency, duration, intensity, maintaining and perpetuating factors. The information was used to device case formulation and management plan for the client.

The client was an average heighted bulky woman wearing a black ‘abaya’. She had neatly done nails and her hygiene was properly maintained. She had her head and face covered but removed the veil in the session room. She sat on the chair while leaning back but her posture was hunched. She gazed towards the floor while talking and kept rubbing her hands. She refrained from touching the table corners or arms of the chair. Her tone and rate of speech was comprehendible. She appeared to have low mood and affect with irritability evident from her frowning. She reported to have frequent obsessions and compulsions. Her long-term memory was intact but she was unable to recall some short term events such as what she ate yesterday or which color clothes did she wear on the day before. She had adequate judgment and abstract thinking. Her insight regarding her problems was present.

The client was asked to rate her symptoms on a scale of 0-10 with 0 being the least problematic and 10 being the most. The scale helped in indicating which symptoms were to be prioritized and dealt first. The treatment of most intrusive symptoms also help in subsiding the lower problematic symptoms hence the rating was beneficial with respect to the treatment plan.

Table 2: Symptoms and subjective ratings of the client

Baseline for Obsessions and Compulsions

A baseline was given to the client to gain detailed information about her symptoms. The baseline incorporated minute details about the client’s obsessions such as the content of thoughts and the meaning client associated to those thoughts. Moreover the baseline also constituted information about the compulsions of the client which she did to satisfy her thoughts and the time taken in performing those compulsions. The chart also encompassed information about client’s emotional reactions and their intensities.

Table 3: Quantitative Analysis of baseline

Table 4: Qualitative Analysis of baseline

Yale-Brown Obsessive Compulsive Scale (Y-BOCS)

            The scale was a 10 item measure assessing he frequency of obsessions and compulsions, distress felt due to them, resisting them and control over them. Its options consisted of 0 to 4 where 0 indicated absence while 4 indicated extreme severity of the symptom. The client attempted the scale in 20 minutes.

Table 5: Score and level of severity of patient on items of Y-BOCS

Table 6: Overall score of patient on Y-BOCS

The client’s total score was 27 which fell in the category ‘severe’ indicating that her symptoms were intense and were causing disturbance in her life. She reported extreme severity in feeling distressful about her symptoms and lacking control over her obsessions. Moreover, her scores also show that she felt very little control over her compulsions and also felt extreme distress about them.

Summary of Formal and Informal Assessment

The informal assessment of the client shows the presence of frequent obsessions and the performance of compulsion in response to them. The visual analogue shows that all of the client’s symptoms were highly problematic but obsessions and compulsions were the most intrusive. The frequency, intensity and duration of the compulsions also showed disturbance in her personal and domestic life.

300.3 (F42): Obsessive-Compulsive Disorder

Points in favor according to DSM-5

            The DSM-5 diagnosis of Obsessive Compulsive Disorder requires the presence of at least one of two symptoms; obsessions or compulsions. The client presents with both of them severe enough to warrant clinical attention. Obsessions were identified as being intrusive for the client which made the client feel distressful and so she tried harder to suppress the thought. The compulsions were identified as the repetitive behaviors the client did in order to relieve the anxiety provoked by obsessions. Moreover, the client spent majority of her day satisfying her obsessions thus interfering with her normal daily functioning.

Differential Diagnosis

Major Depressive Disorder: The client did not present with rumination about the past nor were her primary symptoms related to his affect. The low mood and irritability she presented with was due to the irritation and disturbance cause by her primary symptoms i.e. obsessions and compulsions. Moreover, people with MDD do not usually have compulsions so the presence of compulsions in the client points towards the diagnosis of OCD.

Obsessive Compulsive Personality Disorder: The diagnosis of OCPD requires a consistent pattern of orderliness, inflexibility, perfectionism and efficiency since the early adulthood but the client started to experience the symptoms in her late adulthood and after the incident of renovation occurred at her house. The pre-morbid personality of the client does not show any signs or symptoms such as these. Hence, the client was diagnosed with Obsessive Compulsive Disorder.

Idiosyncratic Case Conceptualization

            The client was diagnosed with Obsessive-Compulsive Disorder due to the presentation of her symptoms of repetitive, intrusive thoughts and consequently performing repetitive behaviors to relieve the anxiety cause by those thoughts. Salkoviski et. al (2001) proposed that all human beings have thoughts but when the thought become repetitive and anxiety provoking the become problematic for the person. The individual tends to blame himself for those thoughts or deliberately suppress them. The constant tug-of-war between the thought and its suppression induces negative emotions in the individual causing him to perform behaviors that tend to neutralize that anxiety. These behaviors may be mental acts or overt behavioral responses. The client also presented with the same symptoms that she had repetitive thoughts about uncleanliness. Instead of passing the thought she focused on it and was then compelled to perform the neutralizing behaviors.

Timpano et. al, (2010) studied the relationship between Obsessive-Compulsive (OC) symptoms and types of parenting. They found that OC symptoms were significantly correlated with an authoritarian parenting style. Strict parenting leads to the formation of OC beliefs that have a high ratio of personal responsibility in it and emphasizes greatly on the importance of thought. When these beliefs are triggered they cause OC symptoms. The OC beliefs thus act as mediators between parenting style and OC symptoms. The present client also had strict parents, stringent childhood and conservative upbringing. This formed OC beliefs in her that everything that comes in her mind is because of her and every bad thought is a sin. As her family was religious as well, the concept of sin and punishment was embedded in her belief system making her more prone towards developing OC symptoms.

Rachman (1997) proposed that OCD symptoms usually develop due to the meaning associated with their thought rather than the thoughts alone. This means that the individual has the power to interpret his/her thoughts constructively or in a negative manner. The people who attach negative connotations with the thought content get stuck in a cycle of thinking, interpreting, suppressing and neutralizing. This cycle then forms an OCD cycle which has both obsessions and compulsions driving it. The client was also stuck in the same process where the thought of dirtiness meant that the place was ‘Na-paak’ and it was a sin not to keep cleanliness in the house. The extreme meaning attached to the thoughts then resulted in distress and further, compulsions.

It has been studied that patients with Obsessive-Compulsive Disorder usually have an attentional bias and they are hyper vigilant towards the cues. The cues that were commonly found were repeated checking for contamination and washing.  Scholars found that OCD patients responded more quickly and specifically to OCD relevant cues e.g. a dirty toilet, broken door etc.  (Moritz, Muhlenen, Randjbar & Fricke, 2009; Tata, Liebowitz, Prunty, Cameron &Pickering, 1996). The present client also presented with an attentional bias where she mostly focused on the cleanliness of the house and would notice everyone’s behavior precisely. She would form linkages in every individual’s behavior by focusing on what the person touched first and later. The hyper vigilance and faulty interpretation caused her to react with distress towards her intrusive thoughts.

• Follow up sessions to increase therapeutic compliance and to assess the presence of symptom substitution.
• Increase in social activities and improvement in quality of relationships

Session No.1                                              Time of session: 45 minutes

Rationale: To develop a trustworthy and sound relationship between the client and the therapist. Procedure: Therapeutic alliance was developed active listening by giving the client ample time to express herself and her problems. Unconditional positive regard was practiced by being non-judgmental about the client’s views, underlying issues and intents. Empathy was provided by projecting an understanding view of the therapist and that the client’s problems were being recognized. Outcome: This encouraged the client to open up. . It helped to effectively engage the client in therapy.

Rationale: To obtain a comprehensive account of the development of client’s problems, its predisposing, maintaining and precipitating factors. Procedure: Informed consent was obtained from the client. Information about the client’s symptoms, their intensity and presenting situations were elicited. Moreover, client’s support system, social functioning, familial life and personal views were also obtained in the history Outcome: The client elaborately discussed all her life domains and cooperated with the client in giving every piece of information.

Rationale: To assess the client’s current level of functioning and physical appearance. Procedure: The therapist observed several of the areas herself such as grooming, eye contact, posture, gait, speech etc. While some questions were directly asked from the client i.e. questions about cognitive functioning, mood, insight etc. Outcome: Obsessions and compulsions were the most significant information obtained from the examination.

Rationale : To understand the client’s problems, elicit disorder specific symptoms and obtain a subjective rating of each symptom. Procedure: The client was asked to tell about the symptoms she experienced while the therapist tracked down the relevant and specific details. Moreover, the client rated her symptoms on a scale of 0-10. Outcome: The procedure helped in identifying the specific severity of each symptoms and helped in prioritizing them for treatment.

Homework given: Dysfunctional thought record and chart for obsessions and compulsions

Session No.2                                         Time of session: 45 minutes

History taking (continued), Validation of history from husband, differential diagnoses, formal assessment (Y-BOCS)

Review of previous session: The client herself came up with information which she forgot to tell in the previous session.

Homework review: She did not fill the DTR or compulsions chart

History taking (continued)

Rationale: To fill in the gaps in the history and obtain more information about past life. Procedure: Elaboration was requested from the client on few matters regarding her symptoms, symptom substitution and relationships. Outcome: More information was gained that helped in understanding the client’s disorder and the maintaining and precipitating factors.

Validation of history from husband

Rationale: To cross-check the client’s account with her husband’s verbatim. Procedure: The therapist separately interviewed the client’s husband with the consent of the client and inquired about the problems. a joint interview was also held afterwards which helped in synchronizing the complaints. Outcome: There were slight differences in the client’s verdict and husband’s verdict which were resolved in the joint session.

Rationale : To get a clearer picture of the client’s symptoms and rule out irrelevant diagnosis. Procedure. She was asked to clarify some of the symptoms, while symptoms from other disorders were ruled out. Specific symptoms of OCD were elicited more. Outcome: The differentials helped in confirming the diagnosis of OCD and ruling out GAD or Depression.

Formal assessment

Rationale: To corroborate informal assessment with standardized and developed questionnaires. Procedure: Y-BOCS was administered collaboratively by the client and therapist. The statements not understood by the client were clarified. It took the client 30 minutes to complete the test. Outcome:  The instrument helped in obtaining a qualitative analysis of the client’s symptoms.

Homework given: Dysfunctional thought record and chart for obsessions and compulsions were given again and client was briefed about cooperative and treatment adherence.

Session No.3                                                Time of session: 45 minutes

Psycho-education, Activity Scheduling

Review of previous session: The client trusted the therapist and felt comforted and understood after the previous session

Homework review: The client filled the DTR and obsessions chart. Gaps in the chart were filled during the session.

Rationale: To orient the client towards her symptoms, their development, precipitating factors, treatment plan and prognosis.  Procedure: The client and her husband were educated about the client’s disorder in detail. The psycho-education comprised of Obsessive-Compulsive Disorder, the causes of development of symptoms, its modes of treatment (medical and psychological) and prognostic factors. Normalization involved the provision of information about the incidence and prevalence of the disorder in indigenous population and their recovery rates. Moreover, the client was also briefed about the therapeutic process, length and duration of sessions, role of the psychologist and client herself and the duration in which the effectiveness of treatment will reveal itself. Outcome: This information gave hope to the client about the effectiveness of treatment as she previously thought that there was no cure for her symptoms and she will have to live in the same way throughout her life. The purpose of the therapy was also provided in order to instill internal locus of control.

Psycho-education (Development of symptoms)

Rationale: To make the client understand the process and functioning of her symptoms. To help to educate the client about the intervention point in the cycle. Procedure: The client was socialized with the CBT model by first explaining her each step in Rachman’s OCD cycle. The simple version of the cycle was helpful in educating the client about obsessions and compulsions and where the cycle had to be broken. After the client had occupied an understanding of how both processes operated, the Wells and Mathews model was explained. The client was then encouraged to put her own examples in the model making it idiosyncratically specific. She identified her thought and behaviors readily, but the therapist had to explain the in between process of meta-beliefs and appraisals regarding intrusions. She was explained about the importance of the meaning she attached to her thoughts and how those meanings led to the development of the symptoms. Outcome: Initially, it was difficult for the client to accept the model but various examples from her own life helped to make it simpler and understandable for her.

Activity Scheduling

Rationale : To make the client indulge in productive activities rather than ruminating over her thoughts and to restore the client’s pre-morbid level of functioning. To make her concentrate on other people and other tasks rather than just washing or cleaning. Procedure. In order to introduce distractions and a healthier social life, she was asked to bring groceries for her house and visit her mother or sister twice a week. Outcome: The client agreed to follow the schedule assigned which helped her greatly as she liked visiting her sister. She also felt that she was performing her religious obligation of visiting her mother through this process. The techniques increased her outgoing behaviors and also got her to keep herself maintained and fresh.

Homework given: To complete the tasks given in activity schedule. She was also given the CBT model to read it again daily until the next session.

Session No.4                               Time of session: 45 minutes

Revisiting psycho-education, thought-suppression experiments, worry postponement

Review of previous session: The previous session was thoroughly reviewed to summarize the information given to the client which she received in the last session. The therapist briefly provided with the psycho-education again and also emphasized to follow the activity schedule completely.

Homework review: She follow the activity schedule up to 50% as she could not visit her sister’s or mother’s house during the week. But she took time out to do the groceries and also managed to read the CBT model of OCD almost daily.

Worry-postponement experiment (Wells, 1997)

Rationale: To make the client realize that worrying is in her own control and that she can shut it off whenever she desires. Procedure: She was asked about the times she was really busy and what thoughts occupied her time when she was busy in a particular task. Then she was asked to identify her thoughts when she lied down and was alone. The client’s distressing thoughts mostly occupied her time when she was alone. The thoughts did not occur to her in busy times such as when talking to someone, sitting in a group of people, indulged in cooking etc. Outcome: The procedure was helpful by making the client understand that she was in control all the time. She understood that she could switch the button off whenever she wanted so the thoughts would go away.

Thought-suppression experiments (Wells, 1997)

Rationale: to explain to her that the more she tried to get rid of the thoughts, the more they would re-occur in her mind. Procedure: She was initially asked to think about a blue rabbit for 1 minute. After that, she was asked to stop thinking about the blue rabbit for 1 minute and not let the thought of the rabbit come in her mind again. She was unable to do so which fulfilled the purpose of the experiment. She was then briefed about the rationale of the technique and how it applied to her intrusive thoughts as well. Outcome: The client understood the technique and its rationale. She also realized that only distraction is not the solution to the problems.

Homework given: To complete the tasks given in activity scheduling and try both thought suppression experiment and worry postponement experiment at home. She was also asked to identify half an hour as the worry time when she can sit and think about the distressing thoughts.

Session No.5                                                Time of session: 45 minutes

Verbal Reattribution by normalizing thoughts/worries (concept of mindfulness) and mini survey

Homework review: The client was able to follow the activity schedule completely. She felt happy after visiting her family. She reported that it was unable for her to deliberately bring the distressful thoughts in her mind during the worry-time specified. After practicing the experiments at home, she was also convinced that her worry was in her own control

Normalizing thoughts/worries (concept of mindfulness) (Wells, 1997)

Rationale: To make the client realize the importance of remaining in the present was told along with the effectiveness of viewing situation objectively. Procedure: The client was explained through various exemplifications that thoughts are a person’s own creation and every individual has a different thought about the same situation. So the client was encouraged to see every trigger as a particular situation which she would view without letting her own beliefs and biases come in between. Additionally, she was also explained that an individual comes across hundreds of thoughts during the day but the thoughts on which he focuses will be the ones that would create distress. So the concept and a thought coming and letting it pass by without letting it intrude in the client’s daily functioning was proposed. Outcome: Through repetitive explanations and examples during the session, the client was able to grasp the concept and take control over her thoughts. The information that everyone comes by these thoughts but does not stress over them, significantly clicked the client and helped to convince over the normality of thoughts.

Rationale: To provide the client with evidence about normal thoughts and distressing thoughts. Procedure: A column was made in which 5 people were listed down and each person was asked about the specific thoughts that the client experienced (thoughts of Na-paaki, uncleanliness). They were then inquired if they felt distressed after those thoughts or did any behaviors or actions to reverse the thought. The frequency of thoughts and related behaviors were listed down. Some people were also asked about the interpretation they gave to their thoughts. Outcome: The client felt somewhat relieved that the thoughts are a normal process but the meaning one attaches to them and the neutralizing behaviors are the point that is problematic.

Homework given: To conduct a mini-survey at home as well and to practice mindfulness by focusing on the present and try to let go of thoughts.

Session No.6                                               Time of session: 1 hour

Introduction to Exposure and Response Prevention (ERP), formation of hierarchy, conduction of the first step.

Homework review: The client continued to follow the activity schedule. She also tried to practice mindfulness by focusing on the task she was doing. Moreover, she also completed a mini-survey of 5 people at home by asking about their thoughts and relevant behaviors.

Construction of hierarchy for ERP (Wells, 1997)

Rationale: To reduce the client’s compulsions and train her in dealing constructively with her anxiety by staying in the situation. Procedure: At first, she was briefed about the procedure and what was required by her. All steps were clarified and queries were answered. After the introduction, a hierarchy was developed by the client with the least anxiety provoking situation to the most. Each situation was also given a rating regarding the level of anxiety felt in those circumstances. Outcome: The client was able to construct the hierarchy with the collaboration of the therapist.

Conduction of first step of the ERP (Wells, 1997)

Rationale: To make the client experience distressing thoughts but unable to perform neutralizing actions. Procedure: After listing down the situation, the client was exposed to the least anxiety provoking stimuli and then stopped from performing the anxiety reducing behavior. During the time anxiety ratings were taken across 1-minute intervals. The client was asked to wash her hands and then close the tap after it. At first the client was hesitant and did not close the tap. But after insistence, she closed the tap after which she was asked not to wipe or wash her hands rather let them remain as they were. It was seen that the client’s anxiety reached its peak within 2-3 minutes and remained high for approximately 10 minutes. The anxiety then reduced automatically until it was completely gone. Initially it was difficult for the client to carry on with the technique as she thought she won’t be able to handle the anxiety. Outcome: With repetitive insistence and exposure during the session, the client productively dealt with all her hierarchical situations.

Homework given: The next step of the hierarchy was given as homework and the client was asked to make her daughter sit near her while she was doing it. The co-therapist was designated to refrain the client from performing any neutralizing behavior and also monitor her anxiety.

Session No.7                                          Time of session: 45 minutes

Verbal Reattribution (Questioning the evidence and questioning the mechanism)

Homework review: The client asked about the second step of the hierarchy. She reported that she was able to deal with the second situation in 2-3 days. She repeatedly did it throughout the day and by continuous practice she did not felt the need to perform her previous behaviors. Moreover, she also told that she tried to restructure her thought during ERP as well which helped her continuing with the procedure

Rationale: To make the client identify evidence and counter evidence of thought in order to disconfirm her beliefs. Procedure: The most frequent and distressing thought of Na-paaki was addressed by this technique. She was first asked to define what Na-paaki was and how she got to know that the objects were Na-paak. As the client did not have problems with dirt she did not focus on it. Hence, she had no strong or visible evidence of proving that something was Napaak. She reported that she just felt like the objects were Napaak when someone touched it after coming from outside or visiting the washroom. Outcome: This led to the disconfirmation of her beliefs that when there is no solid evidence of a phenomenon, then how is it possible to have happened. The technique was helpful in thought-event diffusion of the client.

Rationale: To question the client’s understanding of how things got unclean and what ‘Ahkamaat’ have been given regarding Na-paaki in the religion. Procedure: The disconfirmation of beliefs was furthered by discussing empirical quotes (Ayahs and Ahadees) about Napaaki. She herself told how an object or place would become Napaak based on the religious beliefs. The instances were limited (2-3) and she realized that there was a different between dirt and Napaaki. Her belief around the strictness of achieving purity in the religion decreased and she found that it give space and freedom for minor mistakes. Outcome: The whole process of questioning the thoughts affected the client greatly and major improvement was seen after the client was convinced.

Homework given: The client was asked to continue her activity schedule and add a visit to the neighbors’ house in it. She was also asked to question her own thoughts each time they came by finding evidences and convincing her upon the illogical cognitions.

Session No.8                                               Time of session: 45 minutes

ERP continued, Relaxation exercise

Homework review: The client was inquired about her emotions and thought processes across the past week and how she helped herself in coping with the distressing thoughts. The client told that she evaluated evidence regarding each thought that came and tried to reduce the consequent compulsion she previously did by restricting herself and using the techniques learned during session.

Review of previous session: In order to make the concepts more clear and revise them for the client, verbal reattribution strategies were discussed again and all of the client’s ambiguities were answered.

Continuation of hierarchy

Rationale: To make the client exposed towards more anxiety provoking situations and make her deal with them as well. Procedure: The third and fourth step of the hierarchy was carried out in the session. The third step was carried out by asking the client to touch his feet and shoes thoroughly and then refrain from washing hands. She was asked to talk to the therapist randomly and concentrate on handling the situation without carrying out any compulsion. The client was given ample time for her anxiety to reduce from 100% to 10-20%. She was then asked to carry out the third step of touching the floor and then stay in the same situation. The procedure for preventing from washing was followed. Each situation was repeated 2-3 times. Outcome: The client felt extremely distressful in the start. She disagreed on carrying out the task but the therapist tried to reassure the client. After being convinced, the client carried out the task and handled them fairly well.

Progressive muscle relaxation (Bernstein & Borkovec, 1973)

Rationale: To reduce the client’s muscle tension and bodily pain. Procedure: The client was first told the rationale of the technique and how it will help her in the treatment of bodily pains. After that she was told about the 16 muscles that would be focused upon in the exercise. The therapist then demonstrated how each muscle will be tensed and then relaxed. After the elaborate explanation, the client was asked to relax on her chair and then each muscle of the client was focused. She was asked to first tense each muscle then relaxing it. Double time was given for the client to relax each muscle as compared to the duration of tension. The neck, shoulder and thigh muscles were focused more as the client felt more pain in them. Outcome: She understood the procedure and felt relaxed after the exercise.

Homework given: The third and fourth step of the hierarchy was given to practice at home as well. She was also asked to practice PMR daily before sleeping. A handout was given to the client in which a diagram of each muscle was provided in case the client forgot.

Session No.9                                           Time of session: 45 minutes

Doubt reduction techniques, Review and therapy blueprint, Post-assessment

Homework review: She was asked if she did the exercise she was told. The client complied with all the instructions. She did the relaxation exercise 5 days per week before sleeping. She dedicated 20 minutes to the exercise daily. Moreover she continued to do the tasks given in ERP and reported that she felt less anxious now.

Doubt Reduction techniques (Wells, 1997)

Rationale: To that make client’s behavior ‘stand out’ in memory and will consequently reduce the doubt that motivates checking. Procedure: The client was asked to divide each contamination tasks into smaller steps and focus on those steps while they were being done. For example if she went to the restroom, steps such as opening the door, using the toilet, using the water, washing hands, closing tap and coming out of the washroom were defined. She was asked to revise each step while doing it and then consider the task completed. She was also asked to tick mark each activity after they were done by her. Outcome: This made her less doubtful for each task and she revisited each task relatively less.

Relapse Prevention and Therapy Blueprint (Wells, 1997)

Rationale: To revise all techniques and answer all queries of the client. Procedure: The client’s symptoms were first revised with which she initially sought treatment. After the review of problems, solutions that were implemented were focused. Each technique was revised and the rationale of each procedure was explained again. Most effective strategies were also identified. She was also briefed about the steps she would take if future problems occurred and how she should continue the short term goals. Outcome: The review helped in summarizing the therapeutic sessions and to identify most valid techniques.

Post Assessment

Rationale: To assess the difference between the severity of pre-treatment ratings and post treatment ratings of symptoms. Procedure: The client was asked to rate all her symptoms again on a scale of 0-10. Outcome:

Homework given: Therapy blueprint was given. A chart for the frequency and intensity of obsessions and compulsions was given again to determine post-treatment ratings.

Session No.10 (Follow-up session)               Time of session: 45 minutes

Follow-up on the progress of goals.

Homework review: The chart for obsessions and compulsions was revied to determine post-treatment rating of frequency and intensity of obsessions.

Rationale: To check the compliance of client with treatment techniques and to asses the betterment in all symptoms. Procedure: An interview was conducted with the client and her husband to assess the improvement in the symptoms. Outcome: Both the client and her husband informed that she was considerably better and she was trying hard to completely eliminate all her problems.

Therapeutic outcome

The therapy was effective in dealing and subsiding the client’s obsessions and compulsions. It improved the client’s quality of life and made her more cheerful, hopeful and functional. The client’s compliance and strategies increased the outcome of the therapy.

The client was initially reluctant and non-compliant with the therapist’s suggestions but with repeated insistence she started to follow the therapeutic protocol.

The client was irregular in her sessions hence, long gaps occurred between some sessions. The client was requested to follow the schedule so she became regular after 4 th session.

• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.
• Moritz, S., Von Muehlenen, A., Randjbar, S., Fricke, S., & Jelinek, L. (2009). Evidence for an attentional bias for washing-and checking-relevant stimuli in obsessive–compulsive disorder. Journal of the International Neuropsychological Society , 15 (03), 365-371.
• Tata, P. R., Leibowitz, J. A., Prunty, M. J., Cameron, M., & Pickering, A. D. (1996). Attentional bias in obsessional compulsive disorder. Behaviour Research and Therapy , 34 (1), 53-60.
• Timpano, K. R., Keough, M. E., Mahaffey, B., Schmidt, N. B., & Abramowitz, J. (2010). Parenting and obsessive compulsive symptoms: Implications of authoritarian parenting. Journal of Cognitive Psychotherapy , 24 (3), 151-164.
• Wells, A. (1997). Cognitive Therapy of Anxiety Disorders: A practice manual and conceptual guide (1 st ed.). New York: John Wiley & Sons.

            The client was a 32 years old man who had achieved his education up to MBA, was serving as a police officer and belonged to middle socioeconomic family. He came to the Centre for Clinical Psychology with the complaints of shyness, confusion in social situations, inability to talk adequately in front of people on a higher pedestal, sweating, blushing of face, fear of embarrassment, anticipation of negative evaluation, avoidance of social interactions and disturbance in social life. He was informally assessed through a clinical and diagnostic interview, mental status examination, visual analogue, dysfunctional thought record while the Liebowitz Social Anxiety Scale was implemented as formal assessment. After thorough examination, the client was diagnosed with Social Anxiety Disorder. He was treated on the lines of Cognitive Behavior Therapy through the techniques of cognitive restricting, socialization, cost-benefit analysis, assertiveness training etc. The pre and post assessment of the client showed a significant decline in the client’s complaints and symptoms showing efficacy of the therapy.

Age: 32 years

Occupation: Police Officer

No. of Siblings: 3 (1 sister, 2 brothers)

Birth order: First born

The client came to the Centre for Clinical Psychology with the complaints of shyness, confusion in social situations, inability to talk adequately in front of people on a higher pedestal, sweating, blushing of face, fear of embarrassment, anticipation of negative evaluation, avoidance of social interactions and disturbance in social life. The client was referred to a trainee clinical psychologist for the assessment and management of his symptoms.

Table1: Presenting Complaints of the Client

The client’s problems date back to his childhood when he was studying in school for primary education. He was in 5 th grade when he had to go through a rough phase of life and did not have adequate support to go through the phase. During his time in 5 th grade, he was bullied by his seniors multiple times. The client was a naturally shy person and the senior boys of the school took advantage of him. They usually came to him in the recess time and asked him to do favors such as serving them lunch, bringing them food from the canteen, making their practical copies or fetching books from the library. In addition they would confiscate his lunch, geometry and books and also tore down his copies. This happened almost daily which made the client skip school but he was unable to tell his parents about it. He had the perception that his parents will get angry upon him for making excuses and telling lies. His grades declined due to the stress and his relationships with the teachers also declined. His teachers perceived him as a below average student who was not interested in studies and was not confident. The client started to remain in his class during recess and when the teachers noticed his behavior they thought that it was due to his shyness. They held parent teacher meetings to discuss the client’s problems but all of them thought that the grades were low as the client was not interested in studies and school. The client did not share his problems with his siblings or parents neither did he make friends at school. The 5 th grade passed in the same circumstances after which his parents decided to change his school so that the grades may improve.

The next school proved to be better for the client but he was still afraid of the elder boys. The school had better management and kept discipline during the school timing. This made the client focus on his studies more than the issue of people teasing him or bullying him. His grades improved and he made friends in the new place. His teachers started to hold a positive view about him. His performance in sports improved but he never took the initiative to speak in class by himself or taking part in extra-curricular activities. He remained a shy student but academically improved to a greater degree. His studies after that went on without any hurdles. He passed his matriculation and intermediate with above average grades. During his bachelors and masters as well he performed satisfactorily but still remained shy while talking to others especially girls.

After he achieved his postgraduate education, he decided to go into the Police force. He was motivated by his childhood experiences and wanted to stand against bullying. He wanted to overcome his shyness and perform better so applied in the forces and got accepted for the program. Throughout the training program and his 2 years of service he did not face any problem regarding his social behavior. In 2016, he faced another psychological stressor which triggered his current symptoms. He was given a task by his seniors to prepare a presentation which had to be given in front of his superiors and foreign officials. He tried to decline the offer but he was insisted on doing so. The presentation had to be given after a month of the proposal and that month was the most stressful for the client. He consulted each of his colleagues for help and guidance. He prepared the presentation investing all his energy to do a commendable job and practiced innumerably in front of his friends and colleagues. On the day of presentation, he felt extremely anxious and fearful. The client started to give the presentation but felt dizzy and within 5 minutes of presenting, he felt an increase in his heartbeat and excessive sweating. He had to reach for water repeatedly as he felt dizzy but completed the presentation adequately. There was applause round the hall and he was given positive feedback upon his performance. After the presentation, he reported to his immediate senior who gave feedback on his performance. He was told that he was appearing nervous, his voice was shaky, face was flushed red and he was sweating a lot. Along with these comments, positive compliments were also given. The following night, client could not sleep as he kept on pondering upon the comments of his boss.

After the incident, there were frequent episodes of anxiousness, sweating and inability to talk when the client had to talk in his friend’s circle or in professional meetings. He started to assume that his face and ears were getting red and he would feel embarrassed. Whenever the symptoms appeared, he left the situation or meeting. This compromised his performance chart because of which he considered to seek treatment for his issues. He consulted his friends for reassurance and opinion to get better. One of his friends recommended him to see a psychiatrist or a psychologist. He then came to the Centre for Clinical Psychology with his complaints for the management of his symptoms.

He did not report any physical or sexual abuse. He was taking any medications at the moment neither was there a history of accident, injury or organic disease.

            Father . The client’s father was a 65 years old, uneducated business man. He has his own fields in a village where he use to grow crops along with his brother. He was diagnosed with blood pressure for which he took medications. He was a clam natured person who got angry rarely. He rarely expressed his anger and also kept quiet mostly. He was a highly religious person. His relationships with his siblings, wife and children were satisfactory. The client’s relationship with his father was also respectful and caring but due to the client’s shyness he still felt some degree of fear from his father. They occasionally sat down to discuss business matters but the meetings gradually reduced when the client had to move away after his joining in the police force. They still talked over the phone and cared about each other. The client’s childhood experience of bullying was not shared by his father as he thought that his complaints would be misperceived. Other than that, the client was able to discuss most of his issues with his father.

Mother . The client’s mother was in her fifties, educated up to intermediate and was a housewife. The client described her as a shy, calm and down-to-earth person who was always ready to help others. She had no physical or psychological problems. She was also religious and tried to make her children turn towards religion as well. Her relationship with the client was loving and caring. She dedicated her life for the upbringing of her children and always remained concerned about their well-being. The client usually called her mother and shared his problems with her after he entered adulthood.

The client’s parents had a satisfactory relationship betweem them. They had been married for 34 years but the interaction decreased in the last 10 years. Both remained indulged in their work and were satisfied by each other.

First born was client himself.

            Second born brother . The client’s brother was 28 years old currently doing his masters from a reputable university. He was an outgoing, social and cheerful person. He was confident according to the report of the client. The client and his brother had a distant relationship as he always had to behave like the bigger brother. He did not feel interested in his brother’s activities and had to act like a grown up in the house as well. Both the brothers still cared and helped each other in the time of need.

Third born brother . The younger brother of the client was 22 years old and was doing his bachelors in Computer Science. He was an intelligent and above average student. The client’s brothers had mutual understanding and harmony between them but the client himself did not have close bonding with both the brothers. His younger brother also did not get frank with the client out of respect and obedience. The client was treated as a father figure. The client tried to keep his necessities fulfilled and would give him gifts whenever he visited home.

Last born sister . The client’s youngest sibling was his sister who was 20 years old and was studying in a nearby college. She was the most pampered child being the youngest and only sister. The client had immense love for her sister. Although their relationship was also not close as the client lived away but still they had respect and care between them. The client wished all the good for her sister.

General Home Atmosphere . The client belonged to a middle socio-economic family. His household environment was always calm and nourishing. There were seldom fights or screaming. The children were asked to live harmoniously. The authority figure of the house was the client’s father but discussed issues with his wife. The family was moderately social. They visited their relatives house frequently and also treated their guests well.

Birth and Childhood History. The client was born after a complete gestation period of 9 months through a C-section. His vaccinations were properly done and developmental milestones were achieved at appropriate age. The client did not remember much of his early childhood neither had a discussion on this topic with his parents. He reported that he had a neurotic trait of rubbing his fingers whenever he was nervous. He used to rub his nails on his fingers pressing them deeply into the skin. The habit automatically vanished when he entered adolescence.

Educational History. The client started his education at the age of 6 years. He was put in a local school as his father believed that children can excel on their own as well. Until the fourth class the client remained an average and obedient student. In 5 th class, he had to face bullying by the senior boys in school who used the client for various purposes. The client was never physically hit or sexually assaulted but the frequent threats of the seniors kept him scared. The client started to remain in his classrooms and in front of his teachers. His teachers became dissatisfied with his performance and informed his parents about low grades. None of the parents or teachers knew about the bullying neither were they told by the client. After the below average result in 5 th grade, the client’s school was changed and he got rid of the bullies. From 6 th grade onwards, client performance improved but he still remained a shy student he was good in sports but did not take active participation in any of the extra-curricular activities. He continued his education up to masters with satisfactory percentage. He did not have to face any other psychological stressor throughout his academic career, rather maintained healthy relationship with his teachers, colleagues and fellow students. He remained satisfied with his educational life and considered the bullying episode as a learning opportunity.

Pubertal and Sexual History. The client achieved puberty at the age of 4 years when started to notice changes in his genitals, face structure and voice. He did not face any emotional disturbances at that time. The client sometimes watched erotic movies after he hit his puberty but he did not have any history of homosexual or heterosexual experiences. He also did not report any incidence of sexual abuse or harassment.

Occupational History. The client joined the police force after his postgraduate education. Despite being a shy person, he was able to get in, in the job. He had admirable performance at his job in the initial two years. He maintained satisfactory relationship with his seniors. In the 3rd year of his service, the client had to face a stressful situation when he had to give a presentation in front of a hall of senior officers and foreign officials. The client felt extremely nervous and anxious before giving the presentation. Even after the performance, he was given both positive and negative comments but he kept on focusing on the negative ones and thus became more conscious of his actions. After the event, his performance declined slightly as he started to avoid big gatherings or situations in which he may become the focus of attention. On the other hand, the client’s relationship with his colleagues was satisfactory and he presented himself to all friends in the time of need. He also shared his symptoms and problems with two of his close friends who recommended him to seek psychological advice.

Pre-morbid Personality. The client had a shy personality since childhood but he used to remain calm and relaxed while meeting people. He would give answers with adequate speech quality. He was not reluctant in going to gatherings rather encouraged his friends to go out as well. Moreover, he did not use to worry excessively about his appearance or performance. He remained composed in front of his seniors and performed his job well. His frustration tolerance was high and remained steadfast in his work. He had more interactions with his friends, colleagues and relatives before the symptoms started to occur.

Informal assessment was conducted on the following lines

Dysfunctional Thought Record

  clinical interview.

Informed consent was obtained from the client to ensure he was permitting therapy. A clinical interview was held with the client to assess the symptoms and its intensity, duration, settings and frequency. Moreover, the interview helped in eliciting history regarding the client’s presenting complaints, reasons for development, triggering factors and the factors through which the symptoms were being maintained. It also aided in finding the etiological factors and assessing the line of treatment for the client.

The client was a tall heighted man having a muscular built and appearing to be in his thirties. He was wearing neat and tidy clothes and his hygiene was maintained. He sat on the chair with a straight posture and his actions were greatly pronounced. He kept on moving his leg. He maintained less eye contact while talking but kept his hands clenched tightly. His mood and affect were congruent. He appeared to have a pleasant mood at the time of the interview but he reported that he remained irritable mostly. He was attentive towards the therapist and maintained concentration throughout the sessions. His tone of speech was high and rate of speech was fast. His abstract thinking and judgment was also adequately present. He had a fair insight regarding his problems.

The client was asked to rate his problems on a scale of 0 to 10 in order to know her perspective on the degree of problems caused by the symptoms and her priority of dealing with symptoms. He was explained that 0 meant that the problem was least problematic while 10 meant the problem was most problematic. This helped in creating a symptom specific management plan based on the severity and priority of each symptom.

Table 2: Symptoms and their severity according to the client

The client was given a dysfunctional thought record to take into account the cognitive component of his problems. It aided in later conceptualizing the symptoms to him.

Table 3: Areas of the DTR and the client’s responses

Table 4: Areas of the DTR and the client’s responses

            Formal assessment was carried out through:

Liebowitz Social Anxiety Scale

The scale was administered on the client to obtain a detailed analysis of the situations in which he felt anxious and the degree of his anxiety. The scale also tailored to offer the client’s urge to avoid social situations (Liebowitz, 1987).  The scale had 24 questions and the client was asked to rate each question on a scale of 0 to 3 for the level of anxiety and degree to which he wanted to avoid those situations.

Table 5: Area and client’s scores on the Liebowitz Social Anxiety Scale

The client’s score correspond to the very probable level of Social Anxiety Disorder. It is above the cut off i.e. 30 which means that the client had a high probability of having Social Anxiety Disorder. It is clear through the results that the client had an excessive fear of performance anxiety while situations such as calling people, expressing disagreement or interaction with unknown people were not problematic for the client. He expressed the most anxiety in situations where he was the center of attention and the gathering was composed og known people. There was high probability of the client to avoid these situations as well.

Summary of Informal and Formal Assessment

The detailed assessment of the client shows that he considers himself unable to interact or perform in social situations and hence tends to avoid them. He experiences distress, anxiety and irritability in these conditions because of which his social and occupational functioning was being compromised.

(F40.10) 300.23 Social Anxiety Disorder

Differential Diagnoses

Panic Disorder: Panic disorder is diagnosed in an individual when there are recurrent episodes of physiological arousal and his major focus is on the recurrence of the attack. On the contrary, social anxiety disorder is diagnosed when the client has the primary concern of negative evaluation. Moreover, panic attack can be experienced by an individual while he is alone as well but social anxiety disorder is specific to social situation even if it’s the presence of a single person (APA, 2013).

Normative Shyness: Normative shyness is also a trait that is found in many individuals but when it exceeds a certain limit and starts to cause disturbance in social, occupational functioning then it is diagnosed a social anxiety disorder. Moreover the fear of negative evaluation greatly signifies the diagnosis. Due to the presence of concerns regarding scrutiny and evaluation and the disturbance in social and occupational functioning, the client was diagnosed with social anxiety disorder (APA, 2013).

The client had good prognosis as he has fair insight about his issues and was also willing to take the therapy. Moreover, his symptom severity also indicated that they can be controlled and maintained fairly well. His compliance and dedication also increased the prognostic value of therapeutic techniques.

The present client was a 32 years male presenting with anxiety in social situations, confusion when replying inability to talk in front of people and physiological responses. He was diagnosed with Social Anxiety Disorder according to the Diagnostic Statistical Manual. The developmental psychopathology of social anxiety disorder points out that childhood shyness can lead to future acquisition of Social Anxiety Disorder (SAD). Ollendick and Hirshfeld-Becker (2002) studied the developmental causes of SAD and found that children who are shy are not gven proper guidance to tackle with their shyness later develop extreme anxiety in dealing with people or interacting in social situation. They develop a consistent pattern of anxiousness in their repertoire which can contribute to the enhanced risk of developing SAD. The client’s case can be related to this as he was shy from his childhood. He was reluctant in taking initiatives in school as well so the same pattern was being followed now. Hence, his disorder can be attributed to his prior functioning as a child.

McCabe and his colleagues (2010) studied the relationship of bullying in childhood and the increased probability of developing an anxiety disorder. They found that 92% of the individuals who self-reported bullying indeed developed Social Phobia. They attributed that aversive conditioning experiences, such as severe teasing, have been proposed to play a role in the development of social phobia and that the core feature of social phobia is a fear of social situations in which a person may be embarrassed or humiliated. This conditioning thus associates bullying with the acquisition of SAD. The present client also faced bullying in his school years which was kept hidden from authority figures and not handled appropriately. The assumptions and beliefs formed at that time may have now triggered the disorder in the client presently.

Behaviorists believe that social phobia is a result of a two factor conditioning model. That is, a person could have a negative social experience (directly, through modeling, or through verbal instruction) and become classically conditioned to fear similar situations, which the person then avoids. Through operant conditioning, this avoidance behavior is maintained because it reduces the fear the person experiences. There are few opportunities for the conditioned fear to be extinguished because the person tends to avoid social situations. Even when the person interacts with others, he or she may show avoidant behavior in smaller ways that have been labeled as safety behaviors. The client’s dysfunctions were also being held strongly by the two types of conditioning. His incident of performing in front of a room full of senior authority figures, his nervousness and the biased focusing on negative comments given by his boss, made the situations fearful for him so he developed performance anxiety. He started to link further performances with that one incident and believed that the same would occur in all situations and he will be negatively evaluated by all. Because of this, the client was unable to perform in future situations as well.

Cognitive theorists explain SAD in the terms of dysfunctional cognitions and maladaptive thinking patterns. They propose that people with this disorder hold a group of social beliefs and expectations that consistently work against them. Among the beliefs are, ‘I won’t be able to perform adequately’, ‘I must give a 100%’, ‘There is no chance of any mistake’, ‘People may think less off me’. Cognitive theorists hold that, because of these beliefs, people with social anxiety disorder keep anticipating that social disasters will occur, and they repeatedly perform “avoidance” and “safety” behaviors to help prevent or reduce such disasters. The client also presented with the same beliefs. He held unrealistically high social standards and expected himself to perform perfectly in social situations, even though he had never been so vocal or good with expressing himself. Moreover, his negative anticipation and low confidence in himself triggered a self-fulfilling prophecy making it difficult for him to perform in social situations.

Case Conceptualization (Clark & Wells, 1995)

The management plan was devised specific to each symptom on the lines of Cognitive Behavior Therapy.

Long-Term Goals

• Continuation of short term goals
• Follow-up sessions
• Social Skills Training

Session Reports/Management Plan

Session no.1                                          time of session: 45 minutes.

Rationale: To obtain a comprehensive account of the development of client’s problems, its predisposing, maintaining and precipitating factors. Procedure: Information about the client’s symptoms, their intensity and presenting situations were elicited. Moreover, client’s support system, social functioning, familial life and personal views were also obtained in the history Outcome: The client elaborately discussed all his life domains and cooperated with the client in giving every piece of information.

Rationale: To assess the client’s current level of functioning (cognitive, behavioral, affective and general appearance). Procedure: The therapist observed several of the areas herself such as grooming, eye contact, posture, gait, speech etc. While some questions were directly asked from the client i.e. questions about cognitive functioning, mood, insight etc. Outcome: The significant information obtained through MSE was the anxious and irritable mood of the client, less eye contact while talking, shaky voice and fidgeting while talking.

Rationale : To understand the client’s problems, elicit disorder specific symptoms and obtain a subjective rating of each symptom. Procedure: The client was asked to tell about the symptoms she experienced while the therapist tracked down the relevant and specific details. Moreover, the client rated her symptoms on a scale of 0-10. Outcome: The procedure helped in identifying the specific severity of each symptom and helped in prioritizing them for treatment.

Rationale: To maximize the feeling of comfort and straightforwardness between the therapist and the client. Procedure: It was established through emotional reciprocity which included the therapist’s active listening and responding with appropriate non-verbal communication . The therapist also paraphrased repeatedly during the session to ensure clarity of client’s description and make him certain that he was being understood. The client was also given empathy and unconditional positive regard which was practiced by having a non-judgmental attitude during the session and understanding the client’s problems from his point of view. Any verbal or non-verbal of downsizing the issues or considering them less important were avoided. Outcome: The strong therapeutic alliance developed in the initial sessions led to effectiveness of therapy. Rapport was effectively developed with the client it kept the client motivated for treatment throughout the therapeutic process for procedures like homework assignments and other behavioral strategies.

Session No.2                                   Time of session: 45 minutes

History taking (continued), Differential diagnoses, formal assessment (Liebowitz Social Anxiety Scale)

Review of previous session: The history obtained in the first session was reviewed to continue in the current session.

Rationale: To probe more information about the client’s past life and obtain data which was previously unable to get. P rocedure: The client was asked about his symptoms in more detail and about the situations in which he previously felt the same way. His incident of the performing in the presentation was discussed in depth. Outcome: The review of history helped in obtaining more information that would aid in treatment.

Rationale : To obtain a distinct analysis of the diagnoses and rule out implausible ones. Procedure: The diagnosis for Social Anxiety Disorder was probed more while symptoms of Generalized Anxiety Disorder, Social Phobia and Normal shyness were ruled out. Outcome: It helped in confirming the client’s diagnosis of Social Anxiety Disorder.

Formal assessment (Liebowitz Social Anxiety Scale, 1987)

Rationale: To obtain more information about the client’s problems by using standardized and developed tools. Procedure: The client was given a questionnaire during the session. He was explicitly given the instructions needed to complete the test. Items and their options were explained. He was given ample time to complete the questionnaire with ease. Outcome:   He scored high in experiencing anxiety in social situations and experienced significant performance anxiety in those settings.

Homework given: Dysfunctional thought record was given for the client to fill.

Session No.3                                      Time of session: 45 minutes

Psycho-education and normalization, socialization, productive and non-productive worry.

Homework review: The DTR filled by the client was reviewed which helped in identifying the situations in which the client felt anxious, thoughts that occupied his mind and his reactions towards those situations.

Psycho-education and Normalization (Wells, 1997)

Rationale: To educate the client regarding his diagnosis, their causes, development, treatment options etc. Procedure: The client was educated regarding his illness, the triggering and maintaining factor and the fact that his symptoms were experienced by many other individuals. It helped the client in reviewing himself as part of a bigger community rather than being alone in the specific set of symptoms. While discussing about the prognosis of the client, he was told about collaborative empiricism and how therapy was to be conducted. He was educated about his active role in setting the agenda of therapy, setting short-term and long-term goals, his compliance with homework assignments and active communication with the therapist. Outcome: Normalizing the disorder proved comforting and effective for the client. The technique also proved to be beneficial for him to solve his queries.

Rationale: To make the client aware of the development and process of his symptoms. Procedure: The triggering factors in the model such as the particular social situation, assumptions that are activated and consequent behaviors were exemplified with the client to make the symptoms and their formation more explicit. O utcome: The client agreed with the CBT model and understood where intervention was to take place. He helped in identifying more examples from his life as well.

Productive and non-productive worry

Rationale : To make the client know the difference between the benefits and disadvantages of worry. Procedure: A productive worry is a concern about something that is plausible whereas unproductive worry is about useless things or things that have a little chance of happening (Leahy, 2003). He was explained how anticipating worry about events that have a low probability of happening and for which one has the least evidence can make the individual trapped into an unproductive cycle. The cycle does not lead to a solution rather just utilizes the person’s energy making him more tensed, helpless and lethargic. Outcome: He understood the difference between worrying and how he was stressing himself by unproductive worry.

Homework: Psycho-educational material was given to the client to review at home as well.

Session No.4                                     Time of session: 45 minutes

Cognitive restructuring (Double-column), Cost-benefit analysis of thoughts

Review of previous session: Psycho-education and productive and non-productive was briefly reviewed to freshen the client’s understanding.

Cognitive restructuring (Double-column) (Wells, 1997)

Rationale: To make the client identify his cognitive errors Procedure: The client’s dysfunctional thought record was kept in consideration after which thoughts were emphasized. He was briefed about the different cognitive distortions which an individual makes while thinking. Each mistake in thinking was explained with various examples after which the client was asked to identify his own distortions. A double column was made in which the client wrote down his irrational thoughts and identified the distortion by writing it down in front of the thought. Outcome: The client was able to identify mistakes in his thinking which made him realize the role cognitions played in exacerbating his symptoms.

Cost-benefit analysis of thoughts (Wells, 1997)

Rationale: To make the client understand the damage done by maladapative thoughts and confidence gained by positive and adaptive thoughts. Procedure: He was asked to list down the advantages and disadvantages of a maladaptive thought. After the identification, he was given an opposite positive thought and list down the benefits and disadvantages of that particular thought. The client wrote down all the pros and cons which came to his mind. Outcome: The disadvantages of maladaptive thought were more while the benefits of adaptive thought was significant hence indicating to the client that thought was proving to be destructive rather than the situation itself.

Homework given: The bibliotherapy of cognitive distortions was given to the client to take it along with him and identify more distortions in his thinking until the next session.

Cognitive Restructuring (Triple column), Systematic desensitization, Relaxation exercise.

Review of previous session: The client was asked about the confusions he may have regarding the last session. Cognitive distortions were briefly explained again so that restricting may be continued in the present session as well.

Homework review: He was asked if he was able to identify his maladaptive thoughts and mistakes in thinking. He reported that he sometimes became conscious of his negative automatic thoughts and also tried to identify the errors in his thinking.

Cognitive Restructuring (Triple column) (Wells, 1997)

Rationale: To make the client change his maladaptive thoughts into adaptive ones by eliminating cognitive errors. Procedure: The client’s already filled double column was now increased by putting a third column. He was explained about the double standards he was keeping for himself and how his perfectionism was causing him to perform poorly. He was then probed to write down more realistic, rational and adaptive thoughts in the third column which would ultimately help in subsiding his symptoms and realistically help in improving his performance. Outcome: He was able to do the required task easily but had to be constantly recommended to bring the adaptive thoughts into his repertoire rather than just writing them down.

Systematic desensitization (Introduction)

Rationale: To reduce the client’s avoidance behaviors by exposing him to anxiety provoking situations and coping with them. Procedure: The client was briefed about the process of this technique. He was told about the tasks he would be required to do and how he will cope with the situation. Outcome: The client was hesitant in continuing with the procedure but he was convinced with repetitive explanations about how he will benefit from the technique at the end.

Homework given: To continue triple column at home as well and practice to bring rational thoughts in the repertoire. 

Session No.6                                  Time of session: 45 minutes

Relaxation exercises, formation of hierarchy and conduction of first step of Systematic Desensitization.

Review of previous session: The last session was reviewed to freshen the client’s understanding of the process of systematic desensitization so that it could be continued in the current session as well.

Relaxation Exercises

Rationale: To teach the client how to cope with the stressful situations . Procedure: The client was taught progressive muscle relaxation to know the difference between the tensed and relaxed muscles. 16 muscles of the body were focused and altered in making them tensed and relaxed. Outcome: The client understood the exercise well and it helped in relaxing the client’s tensed muscles during stressful times.

Formation of hierarchy and Conduction of first step of the hierarchy (Miltenberger, 1997)

Rationale: To expose the client towards an anxiety provoking situation and try to cope with it. Procedure: The client was first helped in forming a hierarchy in which situations were listed down. The situations were specific in which the client felt anxious. A list was made which incorporated all situations and systematic units of distress were written down against each situation. The list was made in an ascending order depending on the SUDs. The first step in the ladder was to make the client talk to an unknown girl for 10-15 minutes. He was asked to sit in a room where a girl unknown to the client was brought inside. He was briefed before the meeting that he will have to talk to the girl about himself. The therapist constantly monitored the session. The client became confused during the time the girl sat there but eventually discussed his likes and dislikes and general information with her. He had to be prompted 2-3 times. After the meeting, the client was given feedback by the girl he talked to and by the therapist. He was told about his performance and the presence of any symptoms that he had assumed for himself. Outcome: The client was convinced that no one noticed his face flushing or sweating rather were more interested in his answers. He himself made assumptions and got worried upon them. The procedure was repeated again with another girl the therapist knew but the client didn’t.

Homework given: The client was asked to practice relaxation exercises twice a day and also expose himself to a situation where he had to talk to a female colleague. He was told to practice the techniques of cognitive restructuring and deep breathing to cope with the situation.

Session No.7                                  Time of session: 1 hour

Continuation of Systematic desensitization and introduction to mindfulness

Review of previous session: The client was asked about his views regarding the last session and how it helped him. The client gave his own feedback about the things he should have done or said in the two meetings with unknown girls and how he could have improved his performance.

Homework review: The client practiced the relaxation exercises which soothed down his body. Moreover he also attempted to talk to his female colleague. He was able to do it for 5 minutes even though he was anxious. He controlled himself by revising the rational thoughts in his mind.

Continuation of Systematic desensitization

Rationale: To expose the client to more anxiety-provoking situations and habituate the client ot relax himself. Procedure: 3 more steps of the hierarchy were carried out in this session. Talking on the phone in front of strangers, eating in public and talking to 3 unknown people were the tasks carried out by the client. The client was given ample time to stay in the situation and then relax himself by giving positive self-instructions and changing his cognitions. Moreover he also relaxed himself by using deep breathing. Outcome: The client was able to perform all the tasks but with hesitation because of which the tasks were again given as homework to practice at home.

Homework given: The client was asked to practice the hierarchy steps again at home along with the next two steps of the ladder. He was also asked to try to remain in the present in stressful situations according to the principles of mindfulness.

Session No.8                                         Time of session: 1 hour 15 minutes

Systematic desensitization continued, therapy blueprint, post-assessment.

Homework review: He was asked about the hierarchy steps which were to be carried out at home. The client was successful in handling the situations without avoiding them. He had to go through them repeatedly to improve his performance.

Continuation of systematic desensitization

Rationale: To expose the client to the most anxiety producing situation for him. Procedure: The client was asked to come prepared for a 10-slide presentation on his work which he will give to a group of people. The client gave the presentation to 4 unknown people after which feedback was given to him. His assumptions regarding his anxiety symptoms and his performance were discussed in the feedback. Outcome: The client was able to give the performance but with extreme sweating and anxiousness. For this purpose he was recommended to practice and go through this task again and again to get habituated and practice rational thoughts.

Therapy Blueprint

Rationale: To revise all the techniques done in previous sessions and provide a toolbox for the client to use to tackle with his symptoms in the future. Procedure: As the client had to leave early all techniques especially cognitive restricting and systematic desensitization were discussed. Moreover emphasis on positive self-instructions and practice of each technique was emphasized. Outcome: He understood the importance of each technique and decided when to employ which strategy. His confusions regarding the process were clarified.

Rationale: To assess the difference in symptoms of the client from pre assessment. Procedure: The client was asked to rate his symptoms again on a scale of 0-10. He was also asked to attempt the Liebowitz Social Anxiety Scale again. Outcome: There was a significant difference between the pre and post assessment ratings of the client.

Table 7: Symptoms and their severity according to the client  

Table 8: Area and client’s scores on the Liebowitz Social Anxiety Scale

            The pre and post assessment of the client shows that the therapy was efficacious and there was betterment in the client’s symptoms. The client was now able to function better in his life and experience les anxiety in social situations.

Limitations and suggestions

Therapy had to be terminated after 8 sessions as the client had to complete a course in another city. He could not take the sessions further hence he was advised to seek treatment at his new place or come for a follow-up session after his course was over.

Also study: Counseling Case Report Sample

• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author
• Liebowitz, M. R. (1987). Social Phobia. Mod Probl Pharmacopsychiatry 22:141-173
• McCabe, R. E., Antony, M. M., Summerfeldt, L. J., Liss, A., & Swinson, R. P. (2003). Preliminary examination of the relationship between anxiety disorders in adults and self-reported history of teasing or bullying experiences. Cognitive Behaviour Therapy , 32 (4), 187-193.
• Miltenberger, R. G. (1997). Behavior modification: Principles and procedures. United States of America: Brooks/Cole Publishing Company
• Ollendick, T. H., & Hirshfeld-Becker, D. R. (2002). The developmental psychopathology of social anxiety disorder. Biological Psychiatry , 51 (1), 44-58.
• Wells, A. & Clark, D.M. (1997). Social phobia: A cognitive approach. Chichester: Wiley.

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Case Examples

Strongly Recommended Treatments

Jill, a 32-year-old Afghanistan War veteran

Jill had been experiencing PTSD symptoms for more than five years. She consistently avoided thoughts and images related to witnessing her fellow service members being hit by an improvised explosive device. This case example explains how Jill's therapist used a cognitive worksheet as a starting point for engaging in Socratic dialogue.

Tom, a 23-year-old Iraq War veteran

Several published CPT case examples exist in the literature but many find the one in this chapter to be especially helpful: 

Monson, C.M., Resick, P.A., & Rizvi, S.L. (2014). Posttraumatic stress disorder. In D.H. Barlow (Ed.), Clinical handbook of psychological disorders (5th ed., pp. 80-113). New York, NY: Guilford Press. 

Philip, a 60-year-old who was in a traffic accident (PDF, 294KB)

This case example from the European Journal of Psychotraumatology details an assisted self-study application of cognitive therapy for PTSD. Philip developed PTSD and comorbid major depression following a traffic accident. He was treated in six sessions of cognitive therapy with self-study modules completed in between sessions.

Terry, a 42-year-old earthquake survivor

Terry consistently avoided thoughts and images related to witnessing the injuries and deaths of others during an earthquake. He began spending more time at work and filling his days with hobbies and activities. However, whenever he had free time, he would have unwanted intrusive thoughts about the earthquake. In addition, he was having increasingly distressing nightmares. This case example is followed by an excerpt from an in-session imaginal exposure with a different client.

Conditionally Recommended Treatments

Mike, a 32-year-old Iraq War veteran

Mike was a 32-year-old flight medic who had completed two tours in Iraq and discharged from the Army due to his posttraumatic stress disorder.

Eric, a 24-year-old Rwandan refugee living in Uganda (PDF, 28KB)

This document from the Common Language for Psychotherapy Procedures summarizes narrative exposure therapy and includes a case example about a Rwandan civil war refugee living in a Ugandan settlement. Eric had recurring intrusive images and nightmares of seeing his family be shot by armed rebels.