Case History Report

1. Bio data
Name: Mr. N
Age: 25 years
Gender: Male
Education: Bachelors
Birth order: 1st born
Marital status: Unmarried
Number of siblings: 3
Occupation: Jobless
Fathers status: Alive (lawyer)
Mothers status: Alive (House wife)
Date and place of assignment: August 27, 2015. Falah Health Centre Islamabad.
2. Reason for referral
Client was brought to psychiatric Unit of Falah Health Center by his mother for
showing symptoms such as fear of going outside in any social event, talking to unfamiliar
people, speaking in large gatherings, low self- esteem issues and fear that others are
negatively evaluating him. Client is even unable to eat in front of other people.
3. Presenting complaints
The client had been suffering from these complaints for the past 10 years.
According to the client:

Following symptoms were observed according to DSM 5:

Marked fear or anxiety about social situations in which the individual is exposed to
possible scrutiny.
Fear of being negatively evaluated.
Anxiety in out of proportion
Symptoms lasting for more than 6 months
Marked impairment in social life

4. Family history
Client is a 25 years old male, unmarried, belonging to an upper class family. He was
first born in his family and has one younger sister and two brothers. He is very close
to his mother and shares almost everything with her. Client reported to have very
good and healthy relation with his siblings. His father is very understanding of his
problem and wants him to get as much help as he can. Client has overall very
supportive family.
History of psychological illness has not been reported in the family.
5. Past personal history
Clients birth was normal. He achieved all his developmental milestone in
time. He was very shy and introvert child. He was an excellent student but never
participated in any extracurricular activities. He was not close to his class mates
except his two friends who remained with him till matric. He was bullied in school for
never playing with other boys. He lost contact with his two friends after they went to
different colleges. Client moved to Lahore to live with his aunt where he completed
his bachelors privately. After he returned home, his anxiety to meet new people and
interact with them increased. He became afraid to go out with family.
6. History of present illness
Clients problem started 10 years ago when he finished his school. He
experiences severe anxiety when he interacts with unknown people. Client is always
thinking that others are negatively evaluating him and laughing at him. He is unable
to carry on job interviews because of excessive hand sweating and dry throat. He has
refused to meet anyone except family members and does not want to go out at all. He
has lost contact with every friend.

7. Pre morbid personality

The client was an introvert and extremely shy kid. He was sharp and
intelligent but never participated during class discussion even if he knew the answer.
He liked to spend time with his family and play with his siblings. He was never
talkative or outgoing. Client had a peaceful and quite personality.
8. Psychological assessment
Behavioral observation
Client was very tidy and neat. He was sitting in a reserved posture. Client answered
almost all the questions asked by internee but kept looking down. During second session,
he tried to make eye contact but couldnt maintain it for more than few seconds. He made
fists and became very sweaty discussing his bullied childhood.
The tests that were applied are

HTP

TAT

During the tests, he was very attentive and was interested to ask questions related to
tests. TAT indicators showed anxiety and self-distorted issues whereas HTP showed
client is very reserved and insecure.
9. Case formulation
Mr. N is a 25 years old, unmarried man belonging to an upper class family. He
lives with his parents and one younger sister and two brothers. Illness is characterized
by problem with speaking in public, low confidence, fear and anxiety of being judged
or negatively evaluated by others. He is unable to talk to unknown person and could
not carry out interviews for job. He has a healthy relationship with family but wants to
get better because it is affecting his daily life immensely.
Family environment and parenting styles are important for considering the
onset of social anxiety. Parenting, family environment and social factors are closely
related to development of social anxiety disorder. (Christina, A., 1995)
Social anxiety is associated with enhanced ability to detect negative emotions
in others. Anxiety and stress cause people to feel as though they had to be alone.
Anxiety gives the feeling that you are alone, other people are unable to really grasp
what you are going through. It feels if they are causing a lot of pressure on you. (Sara,
B. 1998)
10. Tentative diagnosis
300.23 (F40.10) Social Anxiety Disorder (social phobia)

11. Therapeutic suggestions

Exposure therapy: You will be guided by a professional counsellor to imagine you are
facing the feared situation until you no longer fear it, such as eating in public. Next,
you may go with your counsellor to a public place and eat until, eventually, you can
eat by yourself in public without fear.
Social skills training: This therapy helps you develop the skills you need in social
situations through rehearsing and role-playing. Your anxiety is reduced as you become
more comfortable with and prepared for the feared social situations.
Cognitive restructuring: This therapy helps you learn to identify and improve fearful
thinking to help you better handle social situations.

12. Prognosis
Prognosis of the patient is favourable because the client has insight and he wants to
get better. He is receiving psychological treatment and his family is very supportive.
If all the guidelines are followed then the chances of recovery are greater.
13. Session report
Session I: During the first session, rapport building was established in between the client
and internee and brief information about the client was taken.
Session II: Tests were administered and more information was gathered by asking more
questions related to childhood.
Session III: Some guidelines were suggested for recovery of the problem.
14. Limitations

Multiple tests could not be administered due to lack of time.

Client was extremely shy at first and did not answer comfortably.
Method used for collecting data could be flawed as no proper training was provided
to student
The time was insufficient to get a detailed history from the client