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.

Bio-Data

Name: Y.N.

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

Duration Complaints From 1-3 years Always worried about family members that nothing happen to them From 1-3 years Fear of death remains. The news of the death of an acquaintance should not come From 1-3 years About future, Especially business concerns From 1-3 years I don’t think I will be able to handle the responsibility From 1-3 years There is pain in the body. I can’t sleep From 1-3 years The purpose of life is not understood. The brain is forgiven 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 1st 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 Symptoms Ratings (0-10) Constant worry/ Remaining preoccupied with worry 9 Uneasiness/ irritation/ agitation 9 Fear of dying or hearing someone else’s death news 9 Constant apprehension about the future 9 Inability to control worry 8 Fatigue, muscular tension 8 Sleep disturbances 8  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 Area of WTR Pretreatment Rating Frequency of worrisome thoughts 6-7 times a day Intensity of beliefs on thoughts (NATS) 9 Qualitative Analysis Table 4: Different Areas of Worry Thought Record and Patient’s Responses on Them Area of WTR Functional Analysis Triggering factors Discussions on future plans, memories of deceased father, hearing about someone’s illness, talking to brothers about business Description of Worry Type I What will happen in the future? What if someone passes away? I cannot lose anyone else How will the business carry on? How will I handle future family? What if I will not be able to support wife and children? Description of Worry Type II (worry about worry) Why am I worrying too much? I should not think this much? I will go crazy by thinking continuously I should be able to control my worrying I keep on thinking all day long. Emotions/ Physiological responses Worry, anxiousness, irritability, jitteriness Behavior/ Response Distraction, sleeping, talking to someone, reassurance about everyone’s health 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. Quantitative Analysis Table 5: Raw score and Severity of Problems as assessed by GADS-7 Raw score Cut off Severity (Pre-treatment) 18 15 Severe Qualitative Analysis 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. Quantitative Analysis Table 6: Raw scores on Various Sub-scales Obtained by the Client on the Metacognitions Questionnaire Subscales Raw Scores of Pre-treatment Positive worry beliefs 37 Beliefs about uncontrollability and danger of worry 38 Meta-cognitive efficiency 16 General negative beliefs 23 Cognitive self-consciousness 16 Qualitative Analysis 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. Diagnosis (F41.1). Generalized Anxiety Disorder 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 Rationale Therapeutically Applied Techniques Engagement of the client in therapy and building a trustworthy relationship between therapist and client Supportive work/ Psychoeducation Therapeutic Alliance Collaborative Empiricism Eliciting content of Type I worry and Type II worry to form idiosyncratic case  conceptualization Guided Questioning Advantages/Disadvantage Analysis of worry Identification of Control Behaviors Worry Thought Record Informing the client about the etiology, development, symptoms, mode of treatment and prognosis of the disorder Psycho-education Socializing with the CBT model of GAD Suppression experiments Provide information to the client about normal and pathological worry Normalizing worry Disconfirming positive beliefs about worry and uncontrollability about worry Worry time (Behavioral Experiment) Challenging uncontrollability appraisals/beliefs Questioning the evidence and mechanism Managing Type I worry Problem-solving cycle Distraction Managing somatic complaints such as fatigue, sleep problems, restlessness and body aches Sleep hygiene Deep breathing Progressive Muscle Relaxation Relapse Prevention Therapy Blueprint 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 Techniques 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. Mental Status Examination 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 Session Agenda 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. Techniques 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 Session Agenda 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. Techniques 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 Session Agenda 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. Techniques 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 Session Agenda 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. Techniques 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 Session Agenda 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. Techniques 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. Worry time 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 Session Agenda 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. Techniques 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 Session Agenda 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. Techniques 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 Session Agenda 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. Techniques 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 Symptoms Pre-Assessment Ratings Post-Assessment Ratings Constant worry/ Remaining preoccupied with worry 9 5 Uneasiness/ irritation/ agitation 9 4 Fear of dying or hearing someone else’s death news 9 5 Constant apprehension about the future 9 3 Inability to control worry 8 4 Fatigue/ muscular tension 8 2 Sleep disturbances 8 1  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 Raw score Cut off Severity Pre-treatment rating 18 15 Severe Post-treatment rating 6 5 Mild   Meta-Cognitions Questionnaire Raw scores on Various Sub-scales Obtained by the Patient on the Metacognitions Questionnaire Subscales Raw Scores of Pre-treatment level Raw scores at Post-treatment level Positive worry beliefs 37 15 Beliefs about uncontrollability and danger of worry 38 10 Meta-cognitive efficiency 16 2 General negative beliefs 23 8 Cognitive self-consciousness 16 5 References; American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Revised Comer, R.J. (2006). Abnormal Psychology, (6thed.). 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.