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PRESENTATION
PRESENTED BY- NAVNITA BOSE
IIND YEAR M.PHIL TRAINEE
DEPARTMENT OF CLINICAL PSYCHOLOGY
INSTITUTE OF PSYCHIATRY
KOLKATA
CHAIRPERSON- MS. DOYEL GHOSH
PURPOSE OF THE
PRESENTATION
Discussion on management plan
registered)
Mother tongue: Bengali
Education: studying in
10th standard
Occupation: student
Religion and caste: Hindu
Residence: sub-urban
Family type: extended
Cont..
Family size: 4 Adults: 2
Income:
Income sources: 1. Father
Patients income: nil
INFORMANTS:
Name: S. M. and B.M.
grand-mother
corroborated.
PRESENTING COMPLAINTS:
1. Disturbed interpersonal relationship
2. Acts of deliberate self-harm
3. Episodes of running away from home
4. Impulsivity
5. Multiple Suicidal attempt
6. Low Mood
From
adolescence
CONT.
As reported by the informant, client used to mistrust this boy often
(MALDA) without informing to anyone. Next day, they came back and
went straight to the boys family as the client feared that her father
would not allow her in.
CONT..
Her father was called to the boys house but her father initially
refused to let her in. Then they were taken to the nearby police
station, after which her father allowed her back. This incident
deteriorated the relationship between the two families, but the
client and the boy continued their relationship.
Then she went back to her hostel. During this time, her father
CONT..
Her boyfriend stated that during this time, she once
from her hostel in vacation, she met another boy living in the
neighborhood. This boy was her younger brothers friend. Client
got friendly to him and they started interacting well. She herself
mentioned this to her boyfriend. These interactions used to
make the clients boyfriend angry and he used to repeatedly
ask the client to stop interacting with him. However, ignoring
his boyfriends opinion, client continued talking with this boy.
CONT..
This made her boyfriend upset and he decided to end their
CONT..
This often led to a series of arguments in the house and often
hitting the client which made the client more upset. Previously,
she was upset because even after accepting this boys
proposal, her previous boyfriend did not approach her to
amend things. Such situation continued for around 4-5 days
and on the sixth day, she eloped with the second boy and
married him in temple. However, client denied this marriage
episode while taking the history.
CONT..
According to the client, she did this mainly to make his
previous boyfriend jealous and also she was angry with her
family and she wanted to teach them a lesson.
Within few hours, her father brought her back with the help of
the police. Her father took her to her paternal uncles house
from where she was taken for psychiatric help the following
day.
CONT..
After having the medicines for two days, she felt somewhat better and
her paternal aunty said that there is no need to take the medicines more.
However, medicines were kept with her only. After two days, she
CONT..
After that she was taken to hospital and next day, she was
BIOLOGICAL FUNCTIONS:
SLEEP: unchanged
APPETITE: decreased
SEXUAL INTEREST AND ACTIVITY: not elicited
ENERGY: unchanged.
NEGATIVE HISTORY:
No significant brain injury, no episodes of fit, history not suggestive of
TREATMENT HISTORY:
Treatment done at INSTITUTE OF PSYCHIATRY (IOP)
January 2015- May 2015
Tab Olanzapine 5 mg x---------x-------I
Effects: improvement in mood symptoms
Side effects: weight gain
Compliance was good
PAST ILLNESS:
Past history not suggestive of any significant medical or
psychiatric illness
FAMILY HISTORY:
family
Family rituals: none reported
Cohesiveness: low
Family burden: financial problem
Expressed emotion: sometimes warmth, sometimes hostility and
critical comments
was 6-7 years old, she witnessed the accident, clients mother
had features such as suspecting her husband as having extramarital affair, had a clinging behavior towards clients father,
acts of deliberate self-harm present before her marriage
providing an impression Borderline Personality Disorder
Father: alcohol dependence
PERSONAL HISTORY:
BIRTH AND DEVELOPMENTAL HISTORY:
Full term, caesarian delivery with attainment of developmental
None reported
CONT..
After her mothers death, they often showered more love and care in
order to compensate for her mother. When she was in 4 th standard, she
was sent to hostel as his father was having a tough time a she was not
able to give his children time and used to be sad about her wife
untimely death. Client reported that she liked staying at hostel but
missed her family very much. She was often more cared than her
brother so that she would not think that her brother is cared more and
had a poor equation with her brother.
HOME ATMOSPHERE: Dysfunctional
ache
SEXUAL HISTORY:
She acquired sexual knowledge from friends at the age of 13
history.
GENERAL TEMPERAMENT:
From childhood, client was stubborn and often refused to obey
elders. However, she was not quick tempered and was easily
manageable. She is sensitive to criticism. If anyone would go
against her wish, she would think that everyone is bad. She
liked to share household responsibility, and likes socializing.
COGNITIVE FUNCTIONS:
Orientation:
Time
Intact
Place
Intact
Person
Intact
Date
Intact
Day
Intact
Month
Intact
Year
Intact
OVERALL IMPRESSION: INTACT
Memory:
REMOTE
RECENT
IMMEDIATE
ABSTRACTION:
SIMILARITIE
Aam- kola
Dutoi fruit
harmonium-
dutoi
tabla
korte
Nachte na janle
kore
Jara nachte pare
uthon beka
na bakide theke,
PROVERB
uthon
nachte
gaan
sahajjo
beka
bole
parena,
GENERAL INTELLIGENCE:
INFORMATION
Current
CM:
Mamta
Banerjee,
CALCULATION
Ramayan: Valmiki
Cost of 2 pencils is .5 paisa, how many
pencils can be bought by 20 paise? 8
153- 75= 78
COMPREHENSION
VOCABULARY
JUDGMENT:
PERSONAL
SOCIAL
Cooperative
behaviour
with
Intact
the
satisfactory
satisfactory
clinician
TEST
brigade k dakbo
Envelope: letter box a dhele debo
LOBE FUNCTION:
Was able to do alternate sequence
Was able to draw clock
THOUGHT:
Stream: normal
Form: normal
Possession: no abnormality detected
Content: normal
DIAGNOSTIC FORMULATION:
Indexed client, S.M., female, 16 years old, married(unregistered), Bengali,
with MSE revealing well kempt and tidy appearance, mesomorphic body-
eye-
contact,
rapport
being
easily
established
with
spontaneous
ease,
and
normal
productivity,
relevant,
and
abstraction,
sustained
average
with
general
intact
memory
intellectual
functions,
abilities
with
conceptual
satisfactory
TEST ADMINISTERED:
Temperament-character Inventory (TCI)
Thematic Apperception Test (TAT)
FINDINGS:
TCI:
TEMPERAMEN
T DOMAINS
PERECTILE
RANK
IMPLICATION
Novelty seeking
Harm avoidance
Reward
dependence
Persistence
75
85
50
High
Very high
Average
35
Very low
CHARACTER
PERCENTILE RANK
IMPLICATION
DOMAINS
Self- directedness
Cooperativeness
Transcendence
39.7
39.9
46.5
Very low
Very low
Average
TCI findings suggest that the client tends to be insecure and doubtful even in situations that do not worry
other people. She tends to be inhibited and shy in most social situations and feel easily fatigued. As a
consequence, she needs more reassurance and encouragement than most other and is unusually sensitive
to criticism. She also tends to be impulsive leading to fickleness in relationships and instability in efforts.
TAT:
Environment
Non-nurturant, supportive,
mistrustful
SELF
Ambivalent (mostly
inadequate)
NEEDS
Counteraction, defendance,
harmavoidance
AUTHORITY FIGURES
Same sex: dominating
Opp. Sex: nurturant
NEEDS
Autonomy,
aggression, intraaggression
CONFLICT
Autonomy vs
compliance
Rejection vs
affiliation
Adequacy vs lack
ANXIETY
Being dominated, loss of
love
DEFENSES
Regression, rationalisation,
projection
PSYCHOPATHOLOGY
FORMULATION:
BIO-PSYCHO-SOCIAL MODEL
Mother: impression of
BPD
Father: substance
abuse
Self
Insecure self
Childhood trauma
Mothers suicide,
going to hostel
Early childhood
experience
Invalidation of
emotion, maternal
neglect,
Arguments with
boyfriend, isolated
by relatives
FINAL DIAGNOSIS:
ICD 10
F60.31; Emotionally Unstable Personality Disorder - Borderline
Type
POINTS IN FAVOUR
AGAINST
Impulsivity
Lack of self-control
Acts of self-harm, suicidal attempts
Emotional instability
POINTS IN
PROGNOSTIC FACTORS:
GOOD PROGNOSTIC FACTOR
Average intelligence
Motivation to know about causes
Female gender
Good compliance
warmth
MANAGEMANT PLAN:
Locus of the therapy process: Hospital based set up with one
individual
Focus of the therapy process:
Short term goal:
Engagement in therapy process
Establishing empathetic relationship with the client
Understanding clients interpersonal environment
Psychoeducation
Improving adjustability
Long term :
Improving skills for better interpersonal functioning
Increasing perceived social support
Improving control over emotions
Enhancing problem solving skills
Enhancing coping skills
Modus of the therapy process: Dialectical Behavior
Therapy
and develop the skill to fully accept her and her world as they are
in the moment through four skills modules; 2 of which emphasize
change and 2 emphasize acceptance and to stand still instead of
running away, to work to understand why her life is so hard.
INTERVENTION:
SESSION 1ST:
Case history was taken.
Mental Status Examination was done.
Due to the suicidal attempt the previous night, she was directly
SESSION 2ND:
History was re-clarified from the client and the informant (father and paternal
grandmother
Cost-and-benefit analysis for the self-harming behavior was done for suicidal
behavior
Subjective unit of distress (SUD) was rated to be 9 and BDI score was found to
which required the active participation of the client. The role of homework in
Dialectical Behavior Therapy was also explained
concepts discussed.
did not any express any difficulty with the concepts and appeared
motivated
Her guardians were also very motivated especially her father
He also enquired whether it would be right to send her back to
hostel. After mutual discussion with the client, the father and the
supervisor, it was agreed upon that at present it would be better for
the client to stay with her family only .
THERAPISTS REFLECTION:
Therapist was concerned as she was feeling that whether the
client has really understood the role of psychotherapy in the
treatment or whether the therapist was able to explain the
client properly about the therapeutic process. Presence of a
suicide attempt made the therapist more cautious about how to
proceed in the therapist. However, therapist was feeling glad
about the therapeutic alliance which was established.
SESSION 3rd:
Client was asked to go through her nature of problems as self-
and somewhere could relate with them, how much she will be
able to carry out in the perfect manner, is doubtful.
But she assured that she will try to practice them. After
THERAPISTS REFLECTION:
Therapist was somewhat relieved that she was able to make
the
fact
behind
the
homework
and
its
SESSION 4th:
Homework done.
Have reunited with first boyfriend and was very happy about
that.
Her father was not very happy as he feared that something
She also reported that her father is being severely strict with
her and does not talk with her properly.
Role playing was done with both, the father and the client.
theory of emotion (emotions come and go. They are like waves
in the sea. Most emotions only last from seconds to minutes).
Client was explained about the prompting events (inside and
outside) and how one emotion can prompt the other emotion.
Examples were elicited from the client.
bolteo paris na. takiye j kotha bolte hoye setao Janis na.
Client felt sad and thought that may be her father did not
forgive her for her past deed and was indeed angry with her.
He does not like her anymore
Therapists interpretation: may be your father was undergoing
SESSION 5TH
Review was done.
Client reported of having difficulty understanding the previous
concepts
Re-explanation was done.
Homework done by her was not adequate but was not given
Jar upore rege jao, tar uprei hoyeto pore khub bhalo laga
ashe.
Role play was done again with an example of the past event.
Homework was assigned for the day (to go through the
When asked what was enjoyable in this, she replied that she
was unable discuss her points with her father due to his
behavior and mostly thought her father did not understand
her. After the role play she was able to understand her fathers
position somehow and was glad about that.
THERAPISTS REFLECTION:
Therapist was happy the way therapy was going and was already
aware that every time the client would not do the homework. However,
therapist still worried about her impulsive behavior and was concerned
as to where her impulsiveness would lead to. As improvement in
Borderline personality disorder was rather difficult and was thinking
that whatever the improvement was, it was at very shallow level.
However, therapist reminded herself that she should not devalue the
clients efforts and should encourage herself and the client.
SESSION 6th:
Client had done a suicidal attempt by taking overdose of olanzapine
over visiting her that why he is not visiting her from last few days.
That agenda for the session was not continued and was again pros
feeling despaired. He was also very angry at the client and wanted
her to call off the relationship.
Father was reminded about the clients problems and was asked
to keep patience.
No homework was assigned.
THERAPISTS REFLECTION:
Therapist was disappointed with the clients behavior and felt that she
was not able to help the client properly. Therapist was more
disappointed with herself and did not know how to proceed further. She
was helped by her supervisor in realizing the fact that such instances
will be more common in future and she should be able to handle such
situations, and not getting disheartened by them. Therapist realized
that she not get overly emotional and should go ahead with an
optimistic outlook to the future, hoping for the best but also prepared
for the worst.
SESSION 7th:
Review was done.
Client was feeling guilty about her behavior and was upset
attempt.
Father expressed concern, worry, and anger on daughter.
reported
that
she
was
feeling
better
after
the
THERAPISTS REFLECTION:
Therapist was worried about the clients fathers behavior and
enough
to
listen
the
importance
of
family
SESSION 8th:
Review was done
Client did not do the homework as she had gone to her relatives house.
However, she reported about the improvement in the fathers behavior.
Previous topics were discussed again.
Clients was asked to do the homework and come for the next session.
THERAPISTS REFLECTION:
Therapist was disappointed and was worried that if the same
SESSION 9th:
Review was done
Homework done.
Client reported the she felt the urge to attempt suicide after having
arguments her boyfriend. She was alone at home and could easily have
attempted it. But instead called up her father and went to him. By
doing so she felt better.
She also reported that she could distract herself before her arguments
She was able to identify the cues (sensing emotion) and then could
distract herself.
PLEASE MASTER was introduced.
TREAT PHYSICAL ILLNESS
BALANCE EATING
AVOID MOOD ALTERING DRUGS
BALANCE SLEEP
GET EXERCISE
BUILD MASTERY
Concentrating on studies
Eating ice-cream
THERAPISTS REFLECTION:
Therapist was happy that the client was able to utilize the
SESSION 10TH:
Review was done.
Client had done the homework and was happy with the way things
with the client but her demanding behavior has increased and
sometimes the client refuses to understand his situation.
annoy him and sometimes she does so because she feel angry.
Client had also brought her family album to share her good
THERAPISTS REFLECTION:
Therapist felt that although the client reported of improvement,
SESSION 11th:
Client reported that she got hold of medicines one day in
between the sessions and called up his father to inform him. She
sensed him tensed and replied by laughing that dont worry, I
will not consume them.
Client was praised for her behavior and related it to her
THERAPISTS REFLECTION:
Therapist was happy the way the therapy was progressing and
SESSION 12th:
Review was done.
Client did not do the homework as she got admission in a coaching
center (long term positive change) and was busy with her homework
there.
Client was adviced to do the homework in the next session, however,
the student proposed her, and on rejecting his proposal the boy did
slash his wrist.
interpersonal
effectiveness
exercises
were
suggested such as while talking to someone, changing the
topic; asking for change without buying anything from the
respective shop.
a coaching center and was happy that she was again involved with
something. However, she was afraid about the incident occurred at
school and said that she will try and keep a check on her behavior.
THERAPISTS REFLECTION:
Therapist was happy that the client could relate to her part of
mistake but she was worried that how much she will be able to keep
a check on her behavior in future. And if such incidents keep on
occurring then, it will be not be good for the client.
FUTURE PLANS:
Mindfulness training
Distress tolerance training
THANKYOU..