Journal of ISSN: 2373-6445JPCPY

Psychology & Clinical Psychiatry
Case Report
Volume 2 Issue 4 - 2015
Case of Anxiety
Zafar Iqbal*
Psychotherapist, Pakistan
Received: December 18, 2014 | Published: April 02, 2015
*Corresponding author: Zafar Iqbal, Psychotherapist, Islamabad,Pakistan, Tel: 92-3349585399; Email: @
Citation: Iqbal Z (2015) Case of Anxiety. J Psychol Clin Psychiatry 2(4): 00079. DOI: 10.15406/jpcpy.2015.02.00079

Abstract

The client visited my clinic with her husband. The husband told me about the abnormal behavior. He informed me that the patient breaks her prayers in the middle and runs for ablution (the washing of hands and some other body parts before performing religious rituals or prayers) she keeps repeating this act many times and she spent more than two hours for a single prayer. He further told about her aggressively behavior with him, mother and other family members, he also compliant her self-talking. He also informed about the stammering not with friends but with family members, especially while talking to her mother or husband.

Symptoms

Repeatly ablution; Aggressive behavior; Self talking; Headache; Sleep disorder

Presenting Behavior

She was nervous, anxious and not feeling comfortable when she visited me very first time.

Family History

After getting information from her husband, I interviewed the patient. This was a Semi-Structure interview. I came to know that client’s mother was a school teacher. She was a Strict-mannered lady and was convenience to punish the children to keep them right and obedient. Even the physical punishment to children became a part of her behavior. While the patient’s father was an uneducated person, farmer by profession and a soft tempered man. He was scary of his wife’s harsh behavior. After receiving these information's I met her mother and father. Her mother admitted rather justified her harsh behavior to children as a right manner for teaching. She told me that she used to behave all her children in the same way and not only the client. She treated her student school in the same way. It is worth mentioning that we are Semi Capitalist feudal society and in such societies the punishment is used as a major tool in teaching methods.

Questioning with client’s father was not fruitful in getting useful information about client as he explained that due to his profession he used to remain out of home and spent most of his time in working at fields.

Social History

Client used to spend most of her time out of home. She made acquaintances and friendships at an age of childhood even. She remained quite happy among her friends. It was noted she remained normal in family gatherings even but not while her mother was present in any such gathering. After marriage he did not feel comfortable with her husband and tried to spend most of her time with her friends and it is was only that her husband is Religious teacher in religious school and also son of her mother's sister.

Medical History

The client’s mother though an educated lady and a school teacher but failed to understand the nature of problem of her daughter. She never made any attempt to get her treated from any doctor. This was one of my past clients who convinced them to visit me. The client’s mother even expressed her annoyance to consult me.

Assessment

As the main source of information about client was her mother and client herself, it come clear to me that the major reason of her was her mother as she was main stimulant for stammering. The client felt quite comfortable and enjoyed the company of her classmates at school. But even at school she sometime felt uneasy due to her class teacher, as her mother was also a school teacher. She never felt easy at home for the presence of mother at home. At school when the client was a student of class III her teacher asked him to stand up and explain about a question. This was sudden and unexpected incident for the client as before this she never faced such a situation. Although she was always fluent and never hesitated to answer any question among her friends but this an altogether a new situation for her. She stammered badly while narrating the answer of question by her teacher.

Up-to this stage it was very much clean that the reason for her tattering was stimulus of fear instinct by her mother behavior, especially the role of her mother as teacher. Her mother used to teach her at home also after she returned from school. It may be noted that despite the harsh manner of her mother she replied the questions by her mother without stammering, while at school she stammered because at home the environment was private not the social. While at school in the presence of classmates if became difficult for client to answer the questions by her teacher as she feared the punishment for not answering rightly. She feared that the punishment in the presence of classmate will be insulting. The fear of insult caused the tattering. But her abnormal behavior of making ablutions repeatedly during prayers was intangible as there was apparently no link of this mull behavio0ur to the client’s history up to this stage.

The client was questioned again to know the reasons for this mall-behavior. Her memory was repressed over this issue. Her mother told me that she is closely associated with her elder sister from childhood. Her sister was called to question about the previous history of the client. Her elder sister was a student at a religious school. Her mother told that she was a religious minded from childhood. Her sister revealed during questioned session that when client was at an age of 04 years she (the elder sister) read a religious book to client. In one of the chapter of the said book it was mentioned that the people who do not wash and chastitize there body parts properly before offering prayers will be punished by God after death very harshly. After death while in grave the God will leave snakes and scorpions over the body of deceased. She will be continuously bitten by snakes and scorpions if she had not been made proper ablution for prayers during their life. This acted as a stimulus for fear-instinct. Her fear aroused during prayers regarding proper ablution. This made the clients to break her prayers and run for ablution repeatedly.

It became clear that she is suffering from two different problems. Reason/cause of the first problem i.e. stammering is harsh behavior of her mother which became the stimulus for “Fear Instinct” and for second problem i.e. practicing the ablution repeatedly the reason cause was fear of punishment by God in the grave which acted as stimulus for Fear Instinct. All the symptoms indicated that client suffering from “Anxiety Disorder”

Treatment

Sixty sessions were conducted. Among them first 7 in the initial seven sessions patient was asked to write down her ideas over various topics. First of all topic was ‘Mother’ and the client was asked to write down her experiences with her mother up to the 10 years age of client. The writing of the client was full discontinuity and crosses. The writing was too short. When the cross-questioning was conducted over her writing the client started weeping and crying stress over her nerves was observed.

On second day she was advised to write down about her child friends up to the age of 10 years. This was a very lengthy writing showing no crosses, over writings or gaps. She seemed to be very comfort able during cross-questioning session.

Next the first topic was repeated once again. This time although the writing was a little bit lengthy as compared to the first one but it was still having many crosses and discontinuity. During cross-questioning she was asked to explain about crosses in her writing. It was revealed that she had negative thinking about her mother and at any point during writing such a negative idea emerged in her mind she put down a cross on the paper while expressing her hatred towards her mother she indicated resistance. She started Avoiding eye-contact, stress over shoulders and backside of head and pains in body.

This already indicated she had hated her mother unconsciously. She had intensions to distance herself from her mother (Pain, Pleasure Rule).

During initial 7 session this was revealed that she hated her mother and has desire to distance herself from her mother on the account of harsh behavior of her mother towards her. Which acted as stimulus to ‘Fear Instinct? ?’

Her sheer attempts during her childhood to make friends to escape from the sense of fear on the account of her mother. These friendships acted as a shelter to client. Even after marriage she used to spend most of her time among her friends. She always expressed her personality by the means of her friends positive comments about her. During next 7 sessions she was asked to write down her ideas on the topic ‘Ablution’ and ‘Prayer’ she complained while writing an topic Ablution that she has become blank minded. She was able to write only a few lines over this topic. She told that she has nothing to write and she also expressed the feeling of headache. This indicated that her unconscious had repressed her memory about ablution in the light of reason as stated already.

The next topic given to client was ‘Prayer’ she wrote elaborately on this topic in the light of religious commands about prayer. There was no need for cross-questioning over this topic.

The next topic she was asked to write over was ‘Relation between ablution and Prayer’. There were a lot of crosses in her writing. She told she suddenly suffers from headache while writing on ‘Ablution’ and felt comfortable while writing on ‘Prayer’.

During cross questioning she was questioning about the relation between ablution and prayer. I asked that in the case one does not carries out proper ablution then what will be the result? She started trembling her whole body shivered and she suffered from severe body pains and headache. On viewing her condition I gave him Lexotanil tablet for relaxation. The session of cross-questioning was adjourned at this point. Next day the client told that she had been watching scorpions and snakes in dreams which tried to bite her. This indicated her fear about ablution. At this stage cross-questioning was conducted again, about scorpions, snakes and the relation of ablution to prayer. Within 10 to 15 minutes there was again body shivering, pain and stress. I changed the topic of conversation and began to talk about her friends she was soothed and relaxed over this, I once again started to talk over scorpions and snakes. Again the symptoms of stress appeared. I changed the topic. I made third attempt to talk with her about scorpions and snakes. This time also the symptoms of stress were indicated by patient. It is worth mentioning that each time when the topic of conversation was changed to see her reaction over the questioning about scorpions and snakes she suffered from stress but it was gradually reduced in intensity on each consequent attempt.

On fourth attempt she spoke out about her memory and snakes. She told that at the age of 4 years her sister had read the religious commands from a book to her about proper ablution and the frightening consequences of not performing the proper ablution. She indicated anxiety and unrest while recalling her memory, but this time she did not suffer from headache, body pain or shivering. This indicated that resistance to this specific memory was removed.

During next remaining sessions she was repeatedly given to write over the topics ‘Mother’ ablution and punishment in grave for improper ablution. Cross-questioning was also conducted as per procedure. During this process, positive associations in unconscious about Mother were brought into conscious which were repressed due to fear-instinct. As a result the fear about mother was eliminated and mother was no more a stimulus for client’s fear instinct.

Likewise during these sessions the positive association with God was discussed. The positive aspects of religion and God were brought into light like The Act of God to forgive for the mistaken of human being etc were discussed. This worked to eliminate her fear about proper ablution.

The client was normal after treatment. She has a child now and living healthy life.

Conclusion

  1. Mrs. RA was patient of Anxiety disorder.
  2. There were two basic reasons of disorder. One was the behavior of mother which became stimulus for Fear-Instinct and in result stammering is started and second reason was information by elder sister about punishment in grave due to not proper ablution which in result she started repeatly ablution.
  3. Five sessions per week required for proper treatment.
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