Mental Health Case Study: Symptoms, Social History, Risk Assessment, and Clinical Formulation

This case study describes a 38-year-old female patient struggling with exhaustion, sleep problems, and relationship issues. The patient's social history is discussed, including financial struggles and lack of emotional support. The risk assessment includes physical and mental health issues, medication overdose, and inability to perform daily tasks. The structured clinical formulation covers the patient's presentation of the problem, predisposing factors, precipitating factors, perpetuating factors, and protective factors.

TASK 1
The patient is 38 year old female. she is feeling really fed up from last few months. she is
struggling to cope up with the things. she does not have done decent conversation with their children
from past few months as she is feeling miserable. she often got into tears due ordinary things. she
spends her day by simply sitting on the sofas when she does not have to go for work. she used to work
in a supermarket which she is not been going much because she is feeling exhausted. she is struggling in
paying the bills and fulfilling the demand of children as her wages were cut down, she is struggling all
around. she spend her night watching the clock and struggles for decent sleep, It take couple of hours to
go into sleep and she often wake up during the sleep that means she has disturbed sleeping pattern.
when she wake up the next morning she feels totally exhausted which could be due to inadequate sleep.
From the last few months she has loosed her appetite and loss some weight. she also feeling difficulties
in concentrating over the things and forget some duties which she needs to perform. she does not
bother now to play with the kids and spend time with the friends, get clicked in the photos'. she is
feeling guilty for not bale to support or be available for their kids. Now, she is not concern about her hair
or dress anymore. she also feeling difficulties in maintaining her relationship with her boyfriend.
TASK 2
The social history addresses the families, occupational and recreational aspects from the
patient personal life. As per the case study, the patient is struggling to pay the bills and fulfilling
the demands of her children as the place she used to work is cutting down her wages. she is
divorced women so she might be struggling for basic necessities to fulfil needs of her and
children. she is not emotionally stable, she got into tears on slightest things. she is no more going
out with her friends and clicks photographs. she is disturbed by the behaviour of her boyfriend
who used to call her or text her but now he his pushing her far away. The patient boyfriend is
pressurizing her during the intimate and made her feel that she is useless and have not much
money. The relationship and the lack of money has affected the mental state of patient mostly.
The patient physical health is also not good. she is feeling exhausted and fed up. she is struggling
for sleep and have inadequate apatite due to which she lose weights and wake up exhausted in
the morning. she is not able to concentrate over the thing and remember the work she have to do.
she is feeling guilty for not being available for her kinds when they need her.
TASK 3
Area Aspects
Appearance
looks more than the stated age, sited in
slouched posture, wear loose clothes, not in
groomed look.
Behaviour Rapport behaviour, does not have maintained
the eye contact, very emotional and agitation
Mood feeling exhausted, fed up, sad due to bad
relationship, guilty for not being available for
children, pressurized due to lack of money

and depressed in nature
Affect The patient facial expression is fragile,
restricted openness, sad behaviour,
Speech
Slow speed, monosyllabic answers to
questions, Dull and monotonous speech and
hesitant speech.
form of the Thought The thoughts process are flowing, stating that
what leads to other effects and behaviour.
content of the thought
the thoughts were generally about the feeling
of guilty, betrayal, humiliation, exhaustion
and the fear of losing. Absence of homicidal
or suicidal thoughts.
Perception
patient is positive about her health care
condition as she thinks that she can get
improved health after some counselling
session.
Cognition loss of consciousness, low concentrating
power, often forgot the duties
Insight and judgement The patient is shows positive behaviour as she
is ready to incorporate in the treatment.
TASK 4
The risk assessment include physical environment another factors like overdose of medication ,
failure to concentrate over the things, failure to perform task related to her and kids, absence of take
care, The risk area include physical and mental health issues, medication overdose, the inability to go to
the workplace. The patient is unable to concentrate over the things thus risking her life as well as her
children's life. Previously she as taken the over dose of Paracetamol in future this behavior will risk the
life of her and the kids also. Due to excessive exhaustion she is not going to her workplace regularly
which may lead to loss of payment and poverty. The risk factor may include the sucidal thoughts and
harm to the her children. as this deteriorating behavior will risk the life of surrounding peoples.
TASK 5
The structured clinical formulation:
Presentation of the problem : the patient is feeling exhausted, always have low energy,
experiencing irregular sleeping and have inadequate eating habits which leads to weight loss, she
is facing problems with concentrating over the things , she is no more enjoying the social outing
or the social circle , she is struggling and feeling guilty for the kids and facing difficulties in the
relationship.
Predisposing Factors : female is of 38 year with low self esteems, she has absence of coping
plan of actions and have lack of support from the nearby friends and families except her sister,

she also lacks the power of defense. she is divorced and now gets detached from the social circle,
she has been in an unhappy relationship and she lacks proper job due to which she is unable to
fulfil her excess responsibilities and provide the care of her children's.
Precipitating factors : The patient has faced the betrayal, she has suffering from excess
anxiety, inabilities of her to share her problem with other due to lack of social circle, she also
lack the support from the workplace and she has been in a abusive relationship.
Perpetuating factors : This is same as Precipitating factors. The ongoing stress and worries,
excessive exhaustion, the lack of support from family and friends and the overdose of
medication.
Protective Factor : the patient has no other health problem, No addiction to alcohol, non
smoker, She loves and care her children, she willingly wants to co operated in the further
treatment and looking forward to live the normal life with her children.