Client Information:

 Name: Mr. Kabin Poudel

 Age: 43 years

 Gender: Male (M)

 Date of Birth: 1981, June 16

 Date of Assessment: 2024, Sep 5

 Assessor: Sanjaya Adhikari

Case History:

Mr. Kabin Poudel was here for psychological assessment by his primary care
physician due to complaints of persistent anxiety, difficulties in
concentration, and episodes of unexplained sweating and palpitations over
the past six months. The primary care physician is concerned about the
potential impact of these symptoms on Mr. Poudel's daily functioning and
quality of life.

Background Information:

Personal History:

Mr. Poudel is a 43-year-old male who works as an accountant in a private

firm. He is married and lives with his wife and two children. He reports having
a stable job but acknowledges increasing pressure at work over the past
year. He has no known history of substance abuse or criminal activity. He
describes his childhood as normal and denies any significant trauma or
abuse.

Medical History:

Mr. Poudel has no major medical conditions except for controlled

hypertension, for which he takes Lisinopril. He reports occasional headaches
but no other chronic illnesses.

Psychiatric History:

There is no known history of psychiatric illness or treatment. Mr. Poudel

reports never having sought mental health services before this referral.
Assessment Methods:

Instruments Used:

 Beck Anxiety Inventory (BAI): A self-report inventory measuring the

severity of anxiety symptoms.

 DSM-5 Diagnostic Criteria for Anxiety Disorders.

 ICD-10 Classification of Mental and Behavioral Disorders.

Procedures:

Mr. Poudel completed the BAI in a quiet office setting with no time
constraints. The assessment was conducted face-to-face, with follow-up
questions to clarify responses where necessary.

Behavioral Observations:

During the assessment, Mr. Poudel appeared anxious, frequently fidgeting

with his hands. His speech was rapid, and he often paused to gather his
thoughts. He maintained good eye contact but appeared visibly tense. There
were no observed signs of psychomotor agitation or retardation. His affect
was congruent with his expressed feelings of anxiety.

Assessment Results:

Beck Anxiety Inventory (BAI) Results:

Scor
Item
e

Numbness or tingling 3

Feeling hot 2

Wobbliness in legs 3

Unable to relax 4

Fear of the worst happening 4

Dizzy or lightheaded 2

Heart pounding/racing 4
 Scor
Item
e

Unsteady 2

Terrified or afraid 3

Nervous 4

Feeling of choking 1

Hands trembling 2

Shaky/unsteady 3

Fear of losing control 3

Difficulty breathing 2

Fear of dying 2

Scared 3

Indigestion/discomfort in
1
abdomen

Faint/lightheaded 2

Face flushed 1

Sweating (not due to heat) 3

Total BAI Score: 54 (Moderate to Severe Anxiety)

Interpretation:

Mr. Poudel's BAI score of 54 falls in the range indicative of moderate to

severe anxiety. His primary symptoms include physiological manifestations
(e.g., heart pounding, numbness, sweating), cognitive symptoms (e.g., fear
of the worst happening, fear of losing control), and affective symptoms (e.g.,
nervousness, inability to relax).

DSM-5 Diagnostic Criteria:

Based on the DSM-5 criteria, Mr. Poudel meets the requirements for
Generalized Anxiety Disorder (GAD):

 Excessive anxiety and worry: Present more days than not for at
least six months.
  Difficult to control the worry.

 Anxiety and worry are associated with three (or more) of the
following symptoms:

o Restlessness or feeling keyed up or on edge.

o Being easily fatigued.

o Difficulty concentrating or mind going blank.

o Irritability.

o Muscle tension.

o Sleep disturbance (difficulty falling or staying asleep, or restless,

unsatisfying sleep).

ICD-10 Diagnostic Criteria:

Mr. Poudel's symptoms align with F41.1 Generalized Anxiety Disorder

(GAD) as per ICD-10:

 The client reports persistent nervousness, worry, and tension most

days over the last six months.

 Presence of autonomic arousal symptoms (e.g., palpitations, sweating,

dizziness, dry mouth).

 Presence of symptoms related to chest and abdominal discomfort, and

fear (e.g., fear of dying, losing control).

 The condition causes significant distress and impacts social and

occupational functioning.

Case Formulation:

Mr. Poudel's anxiety appears to be triggered by increasing work-related

stress and is maintained by cognitive distortions (e.g., catastrophic thinking,
fear of the worst happening). The symptoms are exacerbated by physical
arousal responses (e.g., heart palpitations, sweating), which he interprets as
signs of severe illness or impending danger.

Recommendations:

1. Psychological Interventions: Cognitive Behavioral Therapy (CBT)

focusing on cognitive restructuring to challenge catastrophic thoughts
and exposure therapy to reduce avoidance behaviors.
 2. Medication Review: A consultation with a psychiatrist to evaluate the
potential need for anxiolytic medication, such as SSRIs or SNRIs.

3. Lifestyle Changes: Encourage stress management techniques, such

as regular exercise, mindfulness meditation, and breathing exercises.

4. Follow-up: Regular follow-up sessions to monitor progress and adjust

treatment as needed.

Prognosis:

With consistent treatment, including CBT and possible pharmacological

intervention, Mr. Poudel’s prognosis is favorable. He has good insight into his
condition and is motivated to engage in therapeutic activities.

Conclusion:

Mr. Kabin Poudel exhibits symptoms consistent with a diagnosis of

Generalized Anxiety Disorder (GAD) per DSM-5 and ICD-10 criteria. His
anxiety is likely driven by both cognitive and physiological factors, with
significant distress affecting his daily functioning.

Signature:

[Your Name]
[Your Title]
[Your Contact Information]
[Date]

References:

 American Psychiatric Association. (2013). Diagnostic and Statistical

Manual of Mental Disorders (5th ed.). Washington, DC: Author.

 World Health Organization. (1992). The ICD-10 Classification of Mental

and Behavioral Disorders: Clinical Descriptions and Diagnostic
Guidelines. Geneva: Author.
CBT
session
Report
Client Information:
  Name: Mr. Ravi Sharma

 Age: 43 years

 Gender: Male

 Date of Birth: [Date Not Provided]

 Assessment Start Date: [Insert Start Date]

 Assessment Completion Date: [Insert Completion Date]

 Counselor and Psychotherapist: [Your Name, Title, and Credentials]

Session Reports:

Session 1: Introduction and Psychoeducation

 Date: [Insert Date]

 Duration: 60 minutes

 Objective: To build rapport, establish a therapeutic alliance, provide

psychoeducation on anxiety and CBT, and set therapy goals and
expectations.

 Summary:
During the first session, Mr. Sharma was introduced to the therapeutic
process, the CBT model, and the rationale behind it. We discussed his
symptoms, daily challenges, and specific goals he hoped to achieve
through therapy. Mr. Sharma actively participated and expressed relief
at having a structured approach to managing his anxiety. We covered
the basics of how thoughts, feelings, and behaviors interact and create
a cycle of anxiety. Homework was assigned to monitor anxiety-
provoking thoughts and situations in a thought record format.

 Observations:
Mr. Sharma appeared motivated and engaged, openly discussing his
symptoms and concerns. His anxiety level seemed to decrease slightly
as he gained understanding and insight into his condition. He showed a
keen interest in learning more about CBT techniques.

 Plan for Next Session:

Review thought records and begin cognitive restructuring.
Session 2: Cognitive Restructuring

 Date: [Insert Date]

 Duration: 60 minutes

 Objective: To identify cognitive distortions and introduce techniques

to challenge automatic negative thoughts.

 Summary:
We reviewed Mr. Sharma's homework and identified several cognitive
distortions, including catastrophizing ("If I make a mistake at work, I
will lose my job") and overgeneralization ("I always fail at everything").
Techniques for challenging these thoughts were introduced, including
Socratic questioning and evidence-based thinking. Mr. Sharma
practiced identifying his automatic negative thoughts and developing
balanced, more rational alternatives.

 Observations:
Mr. Sharma demonstrated a willingness to engage in cognitive
restructuring exercises. He was able to recognize some of his negative
thought patterns but required support in developing alternative
perspectives. He found this process somewhat challenging but
acknowledged its potential benefits.

 Plan for Next Session:

Continue with cognitive restructuring exercises and introduce
behavioral activation techniques.

Session 3: Behavioral Activation and Exposure

 Date: [Insert Date]

 Duration: 60 minutes

 Objective: To identify avoidance behaviors and develop an exposure

hierarchy to gradually confront anxiety-provoking situations.

 Summary:
This session focused on the identification of situations Mr. Sharma
avoids due to anxiety, such as public speaking and assertive
communication at work. We collaboratively developed an exposure
hierarchy, starting with less anxiety-provoking situations and gradually
moving to more challenging ones. Mr. Sharma agreed to engage in
 graded exposure exercises over the coming weeks, beginning with
small tasks, like speaking up in a team meeting.

 Observations:
Mr. Sharma was initially hesitant about exposure exercises, expressing
concern about potential failure. However, he committed to the
exposure plan, understanding its importance for reducing avoidance
behaviors. His anxiety level appeared to fluctuate, but he showed
determination to face his fears.

 Plan for Next Session:

Review exposure progress, introduce relaxation techniques, and
continue cognitive restructuring.

Session 4: Relaxation Training and Coping Strategies

 Date: [Insert Date]

 Duration: 60 minutes

 Objective: To teach relaxation techniques and develop coping

strategies to manage anxiety symptoms.

 Summary:
We practiced various relaxation techniques, including deep breathing,
progressive muscle relaxation, and guided imagery. Mr. Sharma was
taught how to use these techniques in situations where he feels
anxiety escalating. He reported feeling more relaxed after practicing
these techniques in-session. We also explored alternative coping
strategies, such as positive self-talk and engaging in physical activity.
Mr. Sharma was encouraged to integrate these strategies into his daily
routine.

 Observations:
Mr. Sharma responded well to relaxation exercises, noting a significant
reduction in his physical symptoms of anxiety. He appeared calmer and
more focused, expressing confidence in his ability to use these
techniques outside of sessions.

 Plan for Next Session:

Continue relaxation practice, review progress with exposure tasks, and
introduce problem-solving techniques.
Session 5: Problem-Solving Skills

 Date: [Insert Date]

 Duration: 60 minutes

 Objective: To introduce problem-solving techniques and apply them to

real-life scenarios.

 Summary:
This session focused on teaching a structured problem-solving model:
defining the problem, brainstorming solutions, evaluating options, and
selecting the best course of action. Mr. Sharma practiced applying
these steps to current challenges, such as managing workload and
time effectively. He found the step-by-step approach useful and agreed
to use this model for upcoming stressful situations.

 Observations:
Mr. Sharma actively participated in problem-solving exercises and
appeared to gain confidence in handling anxiety-inducing scenarios. He
appreciated the structured approach and reported a sense of
empowerment in tackling problems methodically.

 Plan for Next Session:

Review the application of problem-solving techniques and begin
preparing for termination and relapse prevention.

Session 6: Relapse Prevention and Termination

 Date: [Insert Date]

 Duration: 60 minutes

 Objective: To review progress, reinforce skills learned, and develop a

plan for maintaining gains and preventing relapse.

 Summary:
We reviewed all the skills and techniques covered throughout therapy,
including cognitive restructuring, behavioral activation, relaxation, and
problem-solving strategies. Mr. Sharma reflected on his progress,
noting a significant reduction in anxiety symptoms and increased
confidence in managing stress. We discussed potential triggers for
 relapse and developed a personalized maintenance plan, including self-
monitoring, regular practice of learned skills, and scheduling follow-up
sessions if needed.

 Observations:
Mr. Sharma expressed satisfaction with the outcomes of therapy and
demonstrated a good understanding of the skills he had acquired. He
appeared optimistic about his ability to continue managing anxiety
independently, though he acknowledged the possibility of future
challenges.

 Plan for Follow-Up:

A follow-up session is scheduled for three months later to monitor
progress and provide additional support if necessary.

Overall Progress Summary:

Mr. Sharma exhibited significant progress over the course of six CBT
sessions. He demonstrated an improved ability to identify and challenge
cognitive distortions, manage anxiety-provoking situations through graded
exposure, and apply relaxation and problem-solving techniques effectively.
His overall anxiety levels have decreased, and his daily functioning has
improved. Mr. Sharma is now equipped with a range of tools to maintain his
gains and prevent relapse.

Prognosis:

With continued practice of the skills learned in therapy and adherence to the
maintenance plan, Mr. Sharma is expected to maintain his improvement. A
positive prognosis is anticipated, contingent on regular self-monitoring and
occasional follow-up sessions.

Recommendations:

 Regular practice of relaxation and cognitive restructuring techniques.

 Continued use of problem-solving strategies for stress management.

 Scheduled follow-up sessions every three months for ongoing support.

 Engagement in physical activity and mindfulness practices to support

overall well-being.

Signature:
[Your Name]
[Your Title, e.g., Counselor and Psychotherapist]
[Your Contact Information]
[Date]