sandra case presentation on cd
- 2. Name: Rayan Khan Age: 10 Years Sex: Male Address: Chandra, Kaliakoir, Gazipur. (Sub-urban) Siblings: 2 Position: Second Religion: Islam Economic status: Middle Class Educational Qualification : Standard five
- 3. The client was referred to BSMMU the from local doctor.
- 4. Stiffness of whole body Inability to flex knee joint Feeling stress and conflict.
- 5. History revealed occasional complaints of body pain for the last 2 months which was being relieved by body massage. One week back the boy complained of body ache and also vomited after having breakfast. He could not attend school that time. He slept for about 2 hours and wake up with stiffness of body and developed inability to flex upper and lower limbs. He was admitted in a hospital, where he regained mobility of the upper limbs but was not able to bend his knees and walked with a stiff gait. His mother noticed that when the child was asleep his limbs were not rigid and would be flexed. The following morning he was able to walk and run. When discharge was planned there was a relapsed of all the symptoms.
- 6. There was no significant past history of psychiatric or neurological disturbances of the child and his parents. Developmental history was reported to be unremarkable. Family relationships were reported to be cordial.
- 7. Mothers pregnancy and birth: During his mothers pregnancy there was no serious illness and his birth was normal and no complication held after birth. Early development: His developmental milestones were normal. According to clients mother, his childhood was normal and there was no separation, emotional problem during childhood. Schooling and higher education: He was a good student from his early childhood of time.
- 8. Past medical illness: Nothing contributory. Past psychiatric illness: Nothing contributory.
- 9. Relationship: Relationship with his own family and friends was good Leisure activities: He enjoyed with reading books, playing and roaming with friends etc Prevailing mood: His prevailing mood was cheerful. Attitudes and standards: He had a good moral standards and normal attitudes.
- 10. Appearance and Behavior: a) General appearance: Normal b) Rapport: Eye to eye contact was present and sustained and rapport was established properly. c) Posture and movement: Normal d) Social behavior: Normal and culturally appropriate social behavior was present. Affect: Depressed. Mood: Emotional liberality Speech: Quantity: Normal speech Quality: Rhythm and volume is appropriate Quality: Relevant.
- 11. Thought: Stream:none Content: none Form: none Perception: None Cognition: Consciousness: intact Orientation: about time, place and person is intact. Attention: patient is attentive. Concentration: concentration is aright.
- 12. Memory : Immediate: Intact Recent : Intact Remote: Intact Intelligence : Average (based on clinical observation) Abstract thinking: Intact Judgment : Intact Insight : Intact
- 14. In depth interview Objective rating: Psychological evaluation using Childrens Apperception Test (CAT) Subjective rating: Total wellbeing (where 0 means lowest level of the wellbeing and 100 means highest level of the wellbeing)
- 15. Predisposing and precipitating factor: A gradual decline in performance was reported He feels discriminated and victimized by his class teacher and expressed strong resentment for not getting required attention and reinforcement from his class teacher.
- 16. Multi disciplinary Management might be required but in this case ,very good response found after Pschycotherapy sessions.
- 17. Five sessions of Pschycotherapy On the first visit the child was seen to be sitting in the chair with his legs held parallel to the ground since he was not able to flex his knees. He was dragging his feet while walking. The child was provided reassurance regarding the management of symptoms. Possible consequences of persistence of symptoms were also discussed. He was made to do movement exercises by slightly moving his feet preceded by deep breathing. As he was moving his feet suggestions of increased flexibility were given. With continued effort of 10 15 minutes he could bend his knees and sit in a normal position for a brief period. His effort to move his lower limbs were encouraged and appreciated. The child was asked to continue the movement exercises at home and given a suggestion that he would flex his knees at right angles.
- 18. In the second session held the next day child walked less stiffly and was able to bend his knees to right angles as suggested. His parents were educated about the psychosomatic nature of his symptoms and advised to encourage him for developing a symptom free lifestyle. They were also told not to pay attention to his complaints of physical symptoms. By the third session held the next day, his gait was normal. He reported to have pain in his lower limbs but was able to flex his knees. He was still unable to bend his knees fully. He was reinforced for the improvement and asked to continue the movement exercises at home and resume all usual activities.
- 19. Addressing the school related issues he was allowed to talk about alternatives available to deal with the current situation. His parents were advised to allow him to communicate his difficulties freely, look at issues objectively and help him develop an adaptive coping style. The child was asymptomatic and had resumed his earlier routine by the fourth session which was held the next day. He was seen once more after a period of one week during which improvement was maintained. Follow up was maintained for 2 more sessions with the parents with a weeks interval in between during which also improvement was maintained. Telephonic contact was maintained up to 3 months during which he continued to be symptom free.
- 20. Social Management The purpose of social management is to readjustment the client in the family as well as in the society To inform the family members, peer groups, school teacher about clients situation To counsel the family members and school teachers to be patience on client To counsel the peer groups to behave properly with the client To help the client for readmission in SCHOOL Social management was covered for this case.
- 21. I have applied the supportive treatment strategy of Social case work for this client Treatment Strategy Purpose Reassurance Self- confidence Providing information Based on clients needs, such as Medication, Disease, Readmission, etc Cognitive behavior therapy cognitive restructuring Psychodynamic therapy addressing symptom connections to trauma and dissociation Ventilation Emotional release, Identifying hidden cause etc Direct Intervention Making favorable or controlling discussion. Advice Social skill development Self- awareness Understanding Himself and manage the stress
- 22. The child was asymptomatic and had resumed his earlier routine.
- 23. Conversion/dissociative disorders is often misunderstood and challenging to diagnose. Prompt intervention is essential to improve outcomes and avoid prolongation of distressing symptoms. Psychoanalysis should be undertaken after excluding neurological causes and other medical conditions as the cause of a patients symptoms, . Acute psychological stress may be found to have precipitated the conversion symptoms, as occurred with our patient. Once the diagnosis is made, treatment generally warrants a multidisciplinary approach that is supportive and includes a mental health professional.