CASE -1

Socio Demographics

The patient, MR. Y, a 17-year-old male high school senior residing in Delhi, currently

in class 11th was brought to the psychiatry department accompanied by his mother. He is the

only biological child of both parents who divorced when the client was 14 years old. His mother

currently works in administration and father worked as a police officer; however, he lost his job

due to excessive drug and alcohol use.

Chief Complaints

By the Patient

“ Ghabrahat aur baichani hai” 6 months

“ Kuch karne ka mann nahi karta” 1 year (TDI)- 9 years

“ Neend nhi aati” 1 year

“ Sochta bhut zyada hoon” 6 months

By the Informant

“ Pareshaan rehta hai”

“ Kaam mei mann aur dhyaan nhi laga pata”

“ Har waqt sochta rehta hai ” 9 years

“ So nhi pata”

“ Aane waale time ke baare mei sochkar pareshaan ho jata hai”

HOPI

Onset: Insidious

Course: Continuous

Progress: Deteriorating

Total duration of illness: 9 years

Precipitating factors: Separation of parents

 The client was apparently doing well in the personal, social and occupational aspects of

life till 2014. The client attends public school and is on the honor roll. Client’s mother reported

that some of his early childhood experiences consisted of witnessing verbal arguments and

physical aggression between his parents. His mother explained the conflict was mainly due to

his dad working long hours, engaging in frequent alcohol use, and being sexually promiscuous

with other women. Currently, the client lives with his biological mother and her significant

other and his three sons ages 10, 8, and 7 years. Client reported getting along well with his

mother’s significant other as well as his sons. The client and his mother reported that they have

a mutually supportive relationship. Client’s mother reported that his biological father currently

resides in a distant town and does not have contact with them due to a previous history of verbal

abuse. The client had been receiving pharmacological treatment from a community-based

mental health agency since March of 2014 after a one-month hospitalization in an inpatient

behavioral health hospital. He was initially diagnosed with major depressive disorder, single

episode, moderate severity and prescribed Prozac (30 mg) for depressive symptoms and

Klonopin (0.25 mg) for anxiety as needed. The client was hospitalized due to a suicide attempt

in which he attempted to hang himself after experiencing chronic stress and anxiety pertaining

to difficulties with his biological father. For example, the patient recalled experiencing anxiety

when discovering his father had been perpetuating an affair and threatened to physically hurt

his mother if he told her about the affair.

The patient continued pharmacotherapy until July 2015 when he was again hospitalized

for one month due to another suicide attempt where his mother discovered him unconscious in

his bedroom after overdosing on prescribed psychiatric medications. The patient explained

feeling overwhelmed with anxiety when attempting to maintain a part-time job at a grocery

store while fulfilling his school and home obligations. After his release in September 2015, he

was referred to therapy to manage his anxiety symptoms.

 The patient and his mother expressed concern about the client’s ability to manage

symptoms of anxiety and worry related to graduating high school, applying to college, and

moving away from the house to attend college.

The client expressed fear of failing and ending up “being alone on the streets.” The

client and his mother recalled him experiencing this type of general worry and anxiety

symptoms for several years. The two previous hospitalizations for suicidal attempts were

triggered by the chronic status of client’s anxiety symptoms combined with interpersonal

conflicts within his family.

In 2016, the client reported having panic attack symptoms approximately four times

each week for the past eight months in which he experienced sweating, shaking, shortness of

breath, feelings of choking, upset stomach, hot flashes, dizziness, feelings of “going crazy,” and

fear of losing control. The client’s recount of the circumstances surrounding the panic attacks

identify that performance expectations (i.e. work and school performance) served as triggers.

The client also described worrying about various areas of his life (i.e., college education,

performance, health, family matters, world events, and dying alone). Additionally, the client

admitted to avoiding socializing and mostly staying home due to fear of scrutiny by others. The

client also reported cutting his arms several times within a month over several months between

15-17 years of age. The client’s mother stated conflict with his biological father exacerbated his

anxiety. Client reported that he has not engaged in cutting since April 2015. He denied any

thoughts or plans related to suicide and stated that cutting himself reduced tension, rather than

attempting to end his life. Client admitted difficulty falling asleep due to an inability to stop

worrying about the "little things." Client and his mother reported that he takes Geoden at night

to help him sleep.

Family History

42 39

17 10 8 7

There was no history of psychiatric illness in the family. The family has no H/O of

suicide.

Personal History

Personal history can by reliable as the mother of the client was available to give this

information.

Birth and early development

The patient had a full-term normal delivery at a hospital with no complication during

the delivery. The patient reported that he met all the milestones in terms of speaking,

walking, etc. at the right time and there were no delays in reaching the milestones.

Behavior during childhood

The patient had a traumatic and stressful childhood where his father was verbally

and physically abusive towards his mother and the client saw his father having extramarital

affair with other women. He did not engage inactivities such as stealing or flighting

frequently. He had cordial relationships with all his siblings and parents in his childhood.
Physical illness during childhood

No physical injuries suffered during the childhood, apart from the head injury due to

brick. The patient did not have history of seizures in his childhood.

School

The patient started school at the age of 3 years, was average at studies, had difficulty

in making friends as the patient was shy and introvert.

Occupation

The patient is currently studying in 11th grade in a public school.

Use and abuse of alcohol, tobacco, and drugs

No H/O of intake of any kind alcohol, cannabis, hallucinogens, inhalants, opioids,

sedatives, hypnotics and anxiolytics, stimulants, tobacco, or any other psychotropic drugs.

Premorbid Personality

Patient’s predominant mood used to be euthymic, he is average in studies and had

difficulty in making friends and in maintaining interpersonal relations with his father. The

client used to spend his leisure time with family and used to actively participate in family

functions and festivals and was responsible his towards family.

Impression: Well, Adjusted.

Mental status examination

General behavior

An adult male moderately built appropriately dressed according to culture, weather,

and gender (pants and top, with hair combed neatly), but well kempt entered the interview

room in normal gait along with his mother, patient sat on the chair offered and greeted that

doctor. The patient was not guarded during the interview, he was responsive and answered all

the questions asked. Eye to eye contact was maintained. Functional rapport could be

established with the client. His psychomotor activity and reaction time was standard.
Affect

His affect subjectively was “mann me ghabarahat se hai” and objectively was

anxious, afraid, worried, the range of affect was not restricted in nature, and was appropriate,

communicable, congruent.

Speech

His speech was in response to questions, and in terms of volume, flow, and tone was

intact, and the speech had intact productivity and was relevant and coherent.

Thought

In thought, the client had no formal thought disorder, the flow of thought was normal.

In terms of content, the client had no delusions, however, has recurrent and persistent

thoughts of restlessness, uncontrollable worry, lack of concentration and muscle tension. The

client had ideas of guilt, and excessive worrying. The patient had previous history of

suicidal ideation or attempts.

Perception

There was no abnormality detected in perception.

Cognition Functioning

Orientation. The client was oriented to time, place, and person.

Attention and concentration. (Measured through digit span and serial subtraction

test) the client’s attention and concentration was intact.

Memory. The client’s immediate memory was intact measured through digit span

test. The client had intact recent memory (measured by asking questions such as address, and
what was eaten by her at dinner) and remote memory (measured by asking questions such as

marriage date, and birth date)

Intelligences.

General information. the patients’ general information was intact, measured by

asking questions about seasons, and the current prime minster and president of the country.

Comprehension. Comprehension was intact. Measured through asking questions such

as what you will do when you feel cold or when it starts raining.

Abstraction. The patient had intact abstraction measure through test of similarity and

differences and proverbs such as “pani ser se upar jana”.

Arithmetic. Arithmetic was intact, measured through simple calculation.

Judgement

The client had intact personal and social and test judgement (assessed through fire

problem).

Insight

The client had grade V/VI level of insight.

Diagnostic Formulation

A 17-year-old unmarried male, studying in 11th grade, belonging to a Hindu nuclear

family of middle socio-economic status, with easy pre-morbid personality, with no history of

psychiatric and medical illness in the family, the present illness has insidious onset,

continuous course, and deteriorating progress for past 9 years (2015 to present), duration

characterized by apprehension (worries about future apprehensions, difficulty concentrating),

Motor tension, dizziness and sweating, excessive fear and anxiety.

 On MSE, has recurrent and persistent thoughts of future misfortunes where the patient

feels that he won’t be able earn money for his family and would become a burden on his

mother, has ideas of guilt, and excessive worrying.

Provisional diagnosis

Generalized Anxiety Disorder (F41.1) as per ICD-10.

Treatment Goals and Plan

Individual cognitive-behavioral therapy associated with the Intolerance of Uncertainty

Model (IUM) was recommended to manage the anxiety contributing to panic attacks and

improve his ability to cope with worry. In particular, the prescribed treatment goal was, “The

Client will develop healthy strategies for dealing with anxiety and stress.” Consistent with the

IUM, there are four main stages of treatment after psychoeducation about the cycle of worry: 1)

worry awareness training, 2) coping with uncertainty, 3) re-evaluating the usefulness of worry,

and 4) improving problem orientation and problem-solving ability. The general plan of treatment

for GAD that was followed for the client is as follows:

Interventions Components and Functions

Test and clinical interviewing of presenting (a) Identify specific content of

problems worries as well as metacognitive
factors
Worry evaluations (PSWQ, MCQ-30, IUS)
(b) Consideration of medication
Standard intake interview/ADIS-IV

Socialization to treatment (IUM treatment model) (a) Psychoeducation about GAD and
cognitive-behavioral therapy

(b) Indicate how GAD involves

motor tension and arousal
(c)
 Indicate how worries are central
to GAD and worries are
reinforced by nonoccurrence

(d) Develop short-term and long-term

goals

Relaxation training (PMR and relaxation

breathing)

Mindfulness training (a) Identify triggers for anxiety and

avoidance

(b) Introduce Patient’s Worry Log

Assessing and confronting avoidance: Exposure

Monitoring worries and assigning “worry time”

Cognitive evaluation and treatment of worrying Step 1: Distinguishing between

productive and unproductive worry

Step 2: Acceptance and Commitment

(a) Advantages and disadvantages of

accepting limitations and
uncertainty

(b) Current examples of acceptance

Step 3: Challenging worried automatic

thoughts (e.g., fortune telling,
catastrophizing, discounting positives, &
personalizing) and maladaptive
assumptions (e.g., cost-benefit analysis)

Step 4: Examining core beliefs about self

and others

(a) Downward-arrow technique on

worries

(b) Ultimate outcome or fear the client

anticipates

(c) Distinguishing between possible and

probable outcomes
 (d) Examples worries for probability
versus plausibility

(e) Identify and modify emotional

schemas (beliefs about emotions as
dangerous, out of control,
incomprehensible, shameful, etc.)

Step 5: Examining fear of failure

(a) Identify beliefs about failure and

introduce rational responding to fear of
failure

Step 6: Using emotions rather than

worrying about them

(a) Practice self-validation for emotional

distress

Step 7: Putting time on the client’s side

(a)Putting time in perspective by

practicing living in the moment,
mindfulness, stretching time, looming-
vulnerability interventions (slowing
down image of impending threat and
identifying intervening or contingent
events)

Interpersonal interventions Assertion training, communication

training, conflict resolution, and couple
therapy

Problem-solving training and apply to situational

sources of stress

Phasing out treatment

Course of Treatment Accompanying Treatment Plan

Consistent with the IUM for treating GAD in adolescents, the client’s treatment consisted

of assessment, socialization to treatment via psychoeducation about worry, relaxation training,

monitoring worries, and cognitive evaluation and restructuring of worry. Although the therapist

did not explicitly introduce the concept of mindfulness, she incorporated worry awareness

training by assigning weekly worry monitoring exercises. In addition, the therapist collaborated

with the client to identify safety behaviors and instructed him to not engage in safety behaviors

or seek reassurance from his mother. During the course of treatment, the client did not present

with any depressive symptoms, suicidal ideation, or non-suicidal self-injurious behaviors. The

first session consisted of a two-hour assessment and a semi-structured interview discussing the

presenting problem, a history of symptoms, and overall functioning. The therapist asked the

client questions on the ADIS-IV pertaining to Social Anxiety Disorder, Panic Disorder, panic

attack symptoms, Agoraphobia, and Generalized Anxiety Disorder. The client was also given the

PSWQ, the MCQ-30, IUS, and the CDI 2 as baseline measures and again at eight weeks of

treatment.

During the course of treatment, the client was given psychoeducation about the three

components of anxiety (i.e., thoughts, physiological responses, and behavior), how anxiety

becomes distressing (i.e., genetic and specific vulnerabilities), and how it is perpetuated (i.e.,

safety behaviors, reassurances, and avoidance). The client agreed with the therapist’s logic and

provided good examples of how anxiety manifests in his life. For example, the client recalled

experiencing anxiety when thinking about being late for work. The client identified his automatic

thought as “it feels like a sin to be late” and discussed experiencing guilt (emotion) and rushing

to work to ensure he is not late for work (behavior). The therapist also provided psychoeducation

about client’s anxious symptoms, the nature and cycle of worry in client ’s life, and introduced

the specific interventions proposed in the IUM of GAD.

 Another aspect treatment of GAD included relaxation training that fosters coping skills

when developing tolerance of uncertainty and confronting cognitive avoidance. The therapist

provided handouts and a guided compact disk on deep breathing and progressive muscle

relaxation (PMR) techniques, practiced the techniques in-session, and instructed the client to

practice the techniques throughout the course of treatment. The client reported regularly

practicing the PMR techniques and quickly adapted the techniques to function within his daily

life. For example, the client stated he frequently curled his toes and tensed his chest as “quick”

means to alleviate stress throughout the day.

Another focus of treatment included the client routinely monitoring his worries via

weekly homework assignments. The client recorded his worries three times per day by

completing The Patient’s Worry Log . The client was instructed to record content for each worry

area including factors in the situation that elicit worry, prediction of what will happen and when,

anxiety rating for each prediction (0–10), rating of confidence in accuracy of prediction (0–10),

actual outcome (i.e. exactly what happened?), and anxiety rating at outcome (0–10). For

example, the client recorded experiencing anxiety about an upcoming four-page paper in which

he made predictions that he would not be able to complete it on time due to time constraints

associated with his work, school, and home responsibilities. He provided an anxiety rating of

seven for the prediction and rated the confidence in the accuracy of his prediction as five. He

completed the assignment three days before the due date; however, his anxiety rating at the

outcome was five because he then began to worry his teacher would grade his assignment

harshly. Furthermore, within his daily monitoring, the therapist instructed the client to identify

and label worrisome thoughts as, “I am having an anxious thought” as opposed to thinking, “I am

anxious” to help the client create an emotional distance and objectively identify the core fear
underlying the worry. Although the client did not consistently bring completed logs, he was able

to easily discuss specific incidents of worry with the therapist. To aid in maintaining motivation

to continue with cognitive restructuring exercises, the therapist discussed the costs and benefits

of tolerating uncertainty and explained how engaging in “what if” questioning provided the fuel

for worry.

The therapist also assigned weekly “worry time” in that the client was required to worry

for 20 minutes per day in between school and work and to refrain from worrying until the

designated time. This method was introduced as a method to help the client realize his worries

seem inconsequential by the time he addresses them and will ultimately decrease his sense of

urgency to immediately respond in a perfectionistic manner to his worries. The client responded

to the prescribed worry time as “silly and unprofitable” and admitted to not engaging in the

prescribed worry time. The therapist reinforced the concept of completing the assignment by

explaining how worry time reduces time spent worrying and provides evidence that client’s

worry is manageable.

Lastly, building on previously learned concepts presented in treatment, the client

received education about and practiced cognitive restructuring of worry via weekly exercises via

self- monitoring. The therapist introduced the Socratic questions worksheet, as part of Treatment

Plans and Interventions for Depression and Anxiety Disorders. The therapist introduced the

concept of cognitive restructuring strategies by eliciting an example of an upcoming anxiety-

provoking situation for the client such as missing a day of school.

The therapist collaborated with client in Socratic questioning to explore predictions,

likelihood ratings, best/worst outcome predictions, examining evidence for and against his

worrisome predictions, and cost/benefits of worrying. On the worksheet, the client provided
lower probability ratings of worst case scenarios such as providing a 25% likelihood rating of his

worst fear actually happening.

On the Socratic questions worksheet, the client indicated statements such as, “I will get

kicked out of school or fail the government because I missed school due to being sick.” The

client utilized several cognitive restructuring strategies. The therapist introduced the concept of

overestimating the likelihood of the worrisome thought occurring. The therapist oriented the

client to the tendency of “catastrophizing” which is viewing the potential negative consequences

of a situation as being the worst-case scenario and unmanageable. The therapist further explained

the likelihood of the client coping or managing the consequences should the feared event occur.

The client agreed and collaborated with the therapist in challenging the tendency to overestimate

the risk of worried thoughts.

Another component of cognitive evaluation and treatment of worrying involved

distinguishing between productive and unproductive worry. The therapist introduced the strategy

for identifying whether a worry is productive (helpful) or unproductive by eliciting examples of a

worrisome thought from the client and systematically questioning the thoughts in order to

differentiate between the two types of worry. The client was able to engage with the therapist

and agreed with her logic. The client reported that utilizing the “checklist” of differentiating

between productive and unproductive worry as helpful in managing his worrisome thoughts

throughout the course of treatment.

Furthermore, the therapist coached the client to cease safety behaviors and confront

cognitive avoidance as they presented throughout the course of treatment. For example, the client

recalled seeking reassurances from his mother about having a place to live while attending

college. The therapist instructed the client’s mother to only provide reassurance twice; after
which, his mother was instructed not to respond to the client’s questions. The client reported

hismother was compliant with the therapist’s instructions. The client also remained

accountable to his safety behaviors by discussing them with the therapist and amenable to the

therapist’s instructions to stop engaging in all safety behaviors.

The client presented for eight sessions and only completed portions of the

recommendedtreatment. The client received psychoeducation about the cycle of worry, worry

awareness- training, strategies for coping with uncertainty, and tools for re-evaluating the

usefulness of worry. The client did not present for two scheduled appointments in a two-month

period, which placed him on a waiting list for therapy per the mental health agency’s policy.

The client did notreturn for therapy.