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Case Study

Disruptive Mood Dysregulation

Presented By

Syeda Mahnoor
Supervised By

Naeem Aslam

Bio Data





16 years

Age of Onset

7 years


Currently in grade 10, matriculation part II

No. of Siblings

Birth Order


Marital Status


Family System


Fathers Occupation Government Clerk


Government School Teacher

Monthly Family

Rs. 60,000 (roughly)


Client and Father

Presenting Complaints
According to Father

According to Client


History of Present Illness

Average student until grade 8
Got science subjects in grade 9 (matriculation
part I)
Tough subjects
Got very low marks, even lower than her friend
Had to repeat the class

History of Present Illness

Clearly irritated mood most of the time
Temper tantrums
Anger manifested in verbal answers and on things
Refusal to do house chores

Personal History
Pre/peri/post natal
Planned biological child
Mother was under the care of a doctor and had regular
No health complications during the pregnancy
Normal delivery without any complication
No previous pregnancies or miscarriages.

Development and Childhood

The client achieved her developmental milestones on
No psychological or any serious physiological problems
Good in studies
Didnt have any attention problems
Made few friends and her friendships did not last very

She wanted her parents to give

her their full attention and got
irritated when they diverted their
attention to her siblings
At the age of 7 years she started
having temper tantrums which did
not stop and became part of her

Family History
Tense home environment
Economical problems
Parental fights

Paternal Grandmother was diagnosed

with depression

Premorbid Personality
Not social
Less friends
Played alone
Sensitive nature


Informal Assessment
Mental Status Examination
Behavioral Observation
Appearance was normal
Neat and tidy clothing

Client could easily understand whatever

was being talked about
Good orientation about herself

Modest way of carrying herself

Good orientation about the date, day,



Easily and clearly explained her problem

She knew why she had come there
She had god memory

Formal Assessment
House Tree Person: to know the ambiguous personality
traits and problem areas
Bender Gestalt Test: to know her visual motor ability level
Rotters Incomplete Sentence Blank: to know her
maladjustment areas and its level
Depression Anxiety Stress Scale: to know the level of
depression, anxiety and stress being experienced by her

HTP: House
Chimney shows warmth but a lot of smoke is coming out
of the chimney indicating a need to release pent up
tension and pressure
Small door indicating reluctant accessibility. The door is
closed showing a guarded personality yet there is a
pathway that indicate willingness to and openness to
access others.
Curtains indicating a desire for social status
Detailed roof is indicating idealization.
The strong and sketchy lines indicate the anxiety of client
(Buck,1966; Hammer, 1998; Jolles, 1971)

HTP: Tree
The tree is placed to the top left indicating emotional
imbalance and a resentment of mothers influence. Also
it indicates a person who uses idealization to escape
reality and having a high, unrealistic need of
Over striving for achievement is present and it can be
seen that client reaches out to meet needs indicated by
outward branches.
General impression: anxiety and frustration
(bolander, 1977; Hammer, 1965)

HTP: Person
Emphasis on hair indicates sexual preoccupation
Line quality is indicating hesitance, indecisiveness, insecurity
Sketchy hands indicate a lack of self confidence
Left placement indicates impulsive behavior and need of immediate
emotional satisfaction
Excessive shading indicates anxiety
Lashes, small nose and belt indicate sexual conflicts and difficulty in
sexual areas. As well as controlled sexual behavior
Spread out fingers show aggression
And emphasis on clothes is showing an excessive need for social approval.
(Buck. 1950; Jolles, 1971; Machover, 1949)

The drawings depict the clients need of affection, care

and acceptance. They also show that she has a high level
of frustration and aggression


The raw score of client on psycho-neurological screening

test (BGT) is 38 indicating that the clients Visual-Motor
Index is 108 with 70th percentile, which falls in the
AVERAGE range.
The Quantitative scoring of organic indicators attributed
that there is no organic impairment.

the client scored 133 showing a high level of
not satisfied with her family relations
wants more attention from her parents
frustrated by the lack of attention and unfulfilled needs
not social yet wants to have friends with whom she can
share her feelings and also have
upset and depressed state of mind
The sentences give an impression of a sad person
striving to be loved and cared for.

The client scored 40 on depression
34 on anxiety
39 on stress
All three raw scores indicate an extremely severe level.
The client has a very high level of depression, anxiety
and stress because of her problem.

Tentative Diagnosis
(according to DSMV)
296.99 (F34.8) Disruptive Mood Dysregulation

Case Formulation
Illness is characterized by irritability, aggression and
frustration towards her parents and siblings
The main reason seen is the lack of attention from
The attachment theory proposed by Bowlby proposes
that the quality of care provided to the child, particularly
sensitivity and responsiveness, leads to a secure
(optimal) or insecure (non-optimal) attachment. In this
case, the parents of the client are unable to understand
her need of their time and affection. Due to their
economic problem they themselves are stressed out

The client has a good prognosis because she was willing
to cooperate to suggestions and therapy.
Her father also listened to the suggestions in a manner
that showed willingness to follow.

Current Treatment
The client was given mild antidepressant and some
Inderal 40 and Lyvat plus

Treatment Suggestions
Stress management: the client should be taught some stress management
techniques for the times when she feels frustrated
CBT: along with stress management, CBT would help to change her thinking
pattern. As she takes everything said and done by her parents to be against
her. Changing her negative thinking pattern to a positive one will also
positively affect her behavior.
Parental training: her parents should be counselled and taught some good
parenting techniques. As seen by the statements given by the client and the
father, it can be seen that her parents are worried about her academic
performance and have become a bit more rigid than is helpful. The rigidity is
further stressing out the client and enhancing her problem.
The parents and clients can together set some rules and stick to them. E.g.
there can be a rule that if the client will do a certain house chore, they will
take her to some park. Or if she gets better marks in a test, they will take her
to meet a friend.