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Case Report

BS Psychology

6th Semester (Morning)

Submitted by

Nayab Jahan

Roll number

21097

Submitted to

Ma’am Zunaira Arshad

Date: 14 Jan, 2022

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Table of Contents
Introduction 4
Overview 4
Context of referral 4
Demographics information 4

Presenting Complaints 4

MSE 4-5

Background History 5

Developmental and Birth History 5

Family history 5
Educational History 5

Occupational History 5-6

Social History 6

Prior illness History 6

Substance use History 6-7

Sexual and Romantic History 6

Legal History 6

Preliminary Diagnosis7
Test Setting 7
Test Administration 7
Interpretation 8

MMSE 8

HTP 8-9-10

BDI 10

BAI 10

RISB 10

DASS11

BGT 11-12

WAIS 12-13
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5P Model 13
Proposed Treatment 13
Conclusion 13-14
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Case Report

Overview
This is a psychological assessment report of Mr. U, 40-year-old married male from Rawalpindi.
Mr. U was a drug abuser and is currently admitted in Ali Rehabilitation center Rawalpindi and is
under treatment from 2 months.

Context of Referral
The purpose of the session was to collect data for my assignment.

Demographic information
Mr. U is a 40-year-old married male with 6 children. Mr. U belongs from a middle-class family.
He has done matric and after that he started working in a hotel, as a Waiter, kitchen helper and
cook as well, until now before admitting in rehab center. He along with his wife and children,
lives in a joint family with his brother and sisters.

Presenting Complaints
Mr. U is involved in drugs i.e., Opium and in drinking i.e., Alcohol. Mr. U complaints that after
using drugs and drinking he mostly involved in fights with friends and family. The client also
reported some somatic problems like Automatic hyperactivity and hand tremor.

Mental Status Examination

Mr. U is a middle age white Male, was a little nervous when arrived for the session. He was
wearing off white kameez shalwar and a brown shawl. He appeared slightly younger than his
stated age. He was too attentive toward all our questions and was giving precise information. He
was really careful and precise in his speech. His tone was really soft and low. Mr. U was really
thoughtful throughout the whole session. He was not showing much affect during the session, he
only became sad while talking about his family and children. He also mentioned that he misses
her children very much. Mr. U really determined that he has to quit drugs and drinking. His
whole thought content was about his family, children and he have to quit drugs. Firstly Mr. U
was actively doing the test but after 4,5 test he became low and tired. He mentioned that he is
little bit tired. Then we started talking to him about general things in order to relax him. After
completing the last test his face expressions were little agitated like he does not want to talk
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more or to perform more tests. He was perceiving things actively. Mr. U mentioned that
“Freedom is a great blessing” which shows how he misses his freedom.

Background History
Birth and Developmental History
Mr. U had normal birth. He had normal physical, cognitive, language and sensory motor
development. He had achieved all the developmental milestones normally without any difficulty.

Family History

Mr. U belongs from a middle-class family. Mr. U lives in a joint family along with his wife, 6
children and his siblings. He had 5 siblings which include 3 sisters and 2 brothers excluding
him. Their birth order is, an older brother and an older sister than come’s Mr. U and then 2
younger sisters and the last one is his youngest brother. The clients father died in 1997 and his
mother died 10 years ago. He also mentioned that his oldest brother has also started using drug
but he is yet not that addicted to it. Mr. U mentioned that his family is really supporting specially
his older brother.

Mr. U mentioned that whenever he gets drunk, he fights with his friends and family. It has been
few years that these fights were increasing day by day. So, his oldest brother and his wife
encouraged him to go to rehabilitation center for proper treatment because he cannot quit on his
own, although he has tried many times. While talking about his family, Mr. U mentioned that his
mother’s death was really disturbing for him because his mother died in his hands because of
heart attack.

Educational History
Mr. U has started his schooling at the age of 6 years from a government school of Dir. He
reported that he was not that good in his studies, his was more interested in playing cricket with
his friends and he wanted to become a cricketer. When he reached in matric his father died
because of which he left his schooling after matric and started working at a hotel to earn some
money and financially support his family.

Occupational History
Mr. U started working at a hotel soon after he had done his matric. He mentioned that he had
worked at many hotels and done different works like Waiter, Cook helper and even as a Cook.
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He said that he even offered to Rehabilitation center that for the time being which he is here he
can help them in the kitchen if they need any. But they refused because they do not involve
patients in Rehab chores. He also mentioned that from hotels he made some friends with whom
he first started drinking.

Social History
Mr. U is not that social, he had few friends at his school level with whom he loved to play cricket
in those days. After starting job at hotel, he made some friends there and with them he started
drinking. It seems that the client had a reserved kind of personality and that’s why he had a small
social circle. Mr. U mentioned that now he does not prefer making friends because he thinks that
due to his friends he had started drinking and he blame them for being involved in drugs.

Prior Illness History

 Client
 Medical Illness.
The client was diagnosed with Typhoid at the age of 22 years from which he then
recovered, other than that he had not suffered from any severe medical illness in the past.
 Psychiatric Illness.
Mr. U did not mention any psychiatric illness history.
 Family
 Medical illness

Mr. U mentioned that his maternal family had a medical history of heart attack and
even his mother had also died because of heart attack. In his paternal family Diabetes
is the disease from which many members are suffering. Now his older brother is also
suffering from diabetes.

 Psychiatric Illness

Mr. U did not mention any family psychiatric history.

Substance use History

As mentioned above, the client reported that from the age of 25 years he started drinking Alcohol
while working at hotel with his friends. After few years he started taking drug i.e., Opium as
well. After using drugs or alcohol he became too much aggressive and had fights with his friends
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and family. So, to address this issue his family specially his older brother and wife had motivated
him to be admitted to rehabilitation center. Mr. U also mentioned that one time he had tried to
withdraw drugs and he had even succeeded for one month but after one month he again started
using it and for that he blames his friends. So, finally he agreed with his family’s decision and
came by his own will with his older brother and became admit in Rehabilitation center for the
treatment.

Sexual and Romantic History

The client reported no sexual or romantic relationships until he got married. Mr. U reported no
sexual or romantic issues between him and his wife. He mentioned that after drinking he
sometimes fights with his wife other than that he had a really good bonding with his wife. She
supports him in every decision and she also helped him making his mind to go for the treatment
in a Rehabilitation center.

Legal History

Mr. U reported no legal history.

Preliminary Diagnosis

Mr. U is diagnosed with Alcohol withdrawal. As his symptoms are meeting the criteria for
Alcohol withdrawal according to DSM 5.

Test Setting
Tests and motivational interview were conducted in the hall of a Rehabilitation center. There
were two sofa’s Infront of each other. There the client was sitting Infront of me. As those sofas
were lying Infront of the door of the hall, it was a little disturbing for me and the client as well
because it was really cold there and people were passing from that door after every few minutes
which was making too difficult for the client and me to hear each other in that disturbing and
noisy environment. So, the setting was not that comfortable for the client because he had to
repeat his sentence due to the noise and disturbance in that hall.

Tests Administered
Following tests were conducted with Mr. U.
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1. Mini Mental Status Examination (MMSE)

2. Human, Tree, Person (HTP)
3. Beck Depression Inventory (BDI)
4. Beck Anxiety Inventory (BAI)
5. Rotter Incomplete Sentence Blank (RISB)
6. Depression, Anxiety and Stress Scale (DASS)
7. Bender-Gestalt Test (BGT)
8. Wechsler Adult Intelligence Scale (WAIS)

Interpretation
Mini Mental Status Examination
Mr. U scored 28 in MMSE which shows that he had no Cognitive Impairment. This was noticed
by me during the test that his Mental status was perfect and which was then confirmed by his
scores during the test. He performed really well in all questions related to his cognitions and
thinking except two questions which were about Repeating a phrase and making a sentence, this
could be possible that as Mr. U is not that educated, he had not performed good in these
questions.

House Tree Person

House.

Mr. U had drawn a normal sized housed with no window, a closed door and a long narrow
pathway. According to Mr. U this is a random person’s house in which a male and a female live
together, they had a good relationship with each other. This shows following of these features of
Mr. U’s personality “Guarded personality, not very social, defensiveness, passivity, lack of
psychological warmth in his home life, abuse children, Withdrawal, weakness of ego boundaries
and constriction “

Tree.

The client had drawn an Apple tree which is more like an abstract tree with detailed leaves and
narrow trunk. According to Mr. U this tree is present in their house in winters and is 10-12 years
of age. This tree shows some of the following characteristics of M., U’s personality
“Withdrawal, Split ego, Segments & concrete thinking, Over-striking for achievement,
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Aggressiveness, sense of insecurity, Regression, inadequacy, more ego strength, Higher need of
nurturance or dependency and this type of people do not distinct their problems and tend to avoid
direct confrontation”

Person.

Mr. U had drawn a small sized person with bizarre features. According to Mr. U he had drawn
himself, a 40-year aged male, he is going toward his house and his future will be good and
different. This drawing show following features of Mr. U’s personality “Hysteric and manic
tendency, restlessness, Fantasy activity, Feelings of inferiority complex, Withdrawal, He do not
want to expose his personality, Self-conscious and shy, Psychosis, Schizoid, Discouragement,
abused child, Helplessness, loss of autonomy, Lack of confidence in productivity, Guilt,
Repressed regression, Desire to be prominent, Genital inadequacy, Powerlessness External
aggression, deterministic element of personality, Insecure, dependent, Aggressive, poorly
adjusted, Depression, Neurotic, apprehensive, catatonics and chronic schizophrenia, Anxiety,
Feeling of inadequacy, Distorted self-image, Infantile behavior, limited vision, rigidity,
Introversion, Self-absorption, and voyeuristic tendency, Poor interpersonal relationship,
Inappropriate feeling, Self-criticism or can’t bear criticism, Weak ego power and don’t want to
face reality”

Interpretation of HTP
Mr. U had drawn a house, tree and person who are interrelated to each other, According to him
the person is going toward his house by the pathway and there is tree outside his house. These
diagrams show that MR. U has a dependent, insecure, Aggressive, abusive (abused child) and
withdrawal personality. He has also some tendencies of Regression, psychosis, depression, self-
criticism, Guilt, Inferiority complex and self-image distortion.

All of these features of his personality were noticed by me during the interview, as he was giving
precise, short and to the point answers to my questions. He was thinking too much while giving
answers to all the questions, which shows that how reserved and insecure personality he has. He
was not giving much details which shows that he does not want to expose himself may be due to
fear of judgment. Mr. U mentioned in his family history that as he lives in a joint family system
and his older brother is the in charge of the house even though Mr. U is also married and has
family in that house, he is the one who has always prevented him from using drugs, he had
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helped him making his mind to be admitted to rehabilitation center and then he admitted him
here. This shows that how much Mr. U is dependent on his older brother, because he is the one
who take cares for his family when he is high due to drugs and that’s why has a felling for loss of
autonomy. While testing and interviewing it seems from his history that how much he is guilty,
self-critical, has inferiority complex and distorted self-image because of drug abuse whenever he
thinks about his family specially his wife and children. Mr. U’s depression in HTP is also
confirmed by BDI’s scoring.

Beck Depression Inventory (BDI)

Mr. U scored 20 in BDI which shows that he has moderate level depression. As he was
extremely sad, guilty, lost interest in things which he usually enjoys, feels like he is being
punished, blaming himself, tired and feeling blue. Mr. U mentioned all these issues during the
interview which he was facing from quite some time and then these symptoms were also
highlighted in BDI. Mr. U’s depression scores are also in congruent or also confirmed in HTP’s
interpretation.

Beck Anxiety Inventory (BAI)

Mr. U scored 20 in BAI which shows that he has low anxiety. He was feeling mild symptoms
like fear of worst happening, nervous and fear of dying, moderate symptoms like numbness,
wobbliness in legs, unable to relax and dizzy. The client was also experiencing some severe
symptoms on anxiety which include hands trembling, shaky and faint sometimes. He mentioned
all these symptoms in interview as well.

So, Mr. U had a low level of anxiety but his symptoms indicates that there are chances that he
can develop moderate or high anxiety in the future.

RISB

Administration.

Mr. U was provided with all the equipment that were necessary to conduct this test. And ask him
to complete these sentences to express his real feeling. Beside of all these instructions; he can
omit any question even more than one.

Behavioral Observation.
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The behavior of the subject was cooperative and he responded well. He filled all questions with
full concentration. At the end sentences he was getting a little bit tired. Mr. U was taking too
much time while thinking about the sentences and then he wrote it down.

Interpretation.

Mr. U scored 116 marks in RISB and the cut off scores are 135, which shows that apparently
there is no problem in his emotional and social adjustment but his scores shows that there is a
possibility of maladjustment in the future. This can be seen in some of his sentences which
shows that he had some kind of inferiority feelings and feelings of inadequacy because of his
involvement in drugs. He also mentioned some of his fears and wishes like he wanted to be with
his family, he really wanted to quit drugs and want to become a good person and to be with his
family again. Mr. U also mentioned in some of his sentences that he became sad whenever he
remembers his home and he really miss them. He also mentioned that Freedom is a blessing.

While performing the test it was noticed that he was taking some time to understand sentences
and to write them down. That’s why he could not understand some of the sentences and as a
result his 4 sentences were not making any sense and are omitted. These behavior shows that he
is vulnerable to emotional and social maladjustment.

Depression, Anxiety & Stress Scale (DASS)

In DASS, Mr. U scored 6 in depression which means he has a normal range depression, which is
not a matter of concern. He scored 16 in Anxiety, which is severe level of anxiety and lastly, he
scored 21 in Stress i.e., severe stress level. All of these symptoms of DASS were confirmed
during the interview.

Hence Mr. U has a severe level of anxiety and stress as he was going through Alcohol
withdrawal.

Bender-Gestalt Test (BGT)

The client scored 04 in BGT which shows that there are some features of Borderline. Mr. U had
made error in rotation of Card A and 7, he had done simplification in Card 8, Perseveration in
Card 1 and Motor incoordination in card 7 and 8. The prominent errors were shown specifically
in drawing of Card 7 and Card 8, in which the lines are irregular. Also, in card 8 difficulty in
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closure of rectangle can be seen. So, all these errors indicate some features of borderline in the
client.

As the scores are not that high and errors in card 7 and 8 i.e., irregular lines, difficulty in image
closure, can be due to the issue i.e., shaky hands which client has mentioned in BDI and in the
interview. So, we can conclude that Mr. U does not have any impairment in visual-motor
functioning, any developmental disorders, and neurological impairment.

Wechsler Adult Intelligence Scale (WAIS)

In WAIS 10 intelligence questions were asked from the client which include some performance
questions as well i.e., Block design, Visual puzzle, mathematical questions and general
questions. Mr. U had performed well in all the questions except 2, which include one
mathematics or numerical question and one is Visual Puzzle.

General Intellectual Ability.

The client’s general intellectual ability is perfectly fine as he has given right answers to all
general knowledge questions.

Verbal Comprehension.

The client’s verbal comprehension is also completely fine as he performed really well in verbal
questions.

Perceptual Reasoning.

Mr. U’s perceptual reasoning is not that good and he could not complete the Visual puzzle and
also could he could do well in numerical questions.

Working Memory.

Mr. U also performed really well in working memory questions, as he has given all right
answers.

Processing Speed.

The overall processing speed of Mr. U was really great as he has answered every question in
almost one minute.
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So, it can be concluded that Mr. U’s intelligence level is quite good. His verbal reasoning
abilities are much better developed than his nonverbal reasoning abilities. Client’s reasoning
abilities on nonverbal tasks are generally in the average range, while his verbal reasoning
abilities are significantly higher and in the superior range.

5P Model

According to assessment Mr. U was suffering from these problems “numbness, wobbliness in
legs, unable to relax, hands trembling, shaky hands, aggressiveness, self-criticism and dizziness”
from past 2 months (Problem). It was found that the person has not any genetic or
developmental predisposition toward substance abuse disorder. However, the problem started
after the death of his father when he had to quit his studies i.e. after matriculation, due to which
he had to start working at a hotel from where he made friends with whom he started drinking
(Precipitating Factor). However, he kept on drinking and drug abusing because of his bad
company, as the client already mentioned above that he belongs from a middle class, joint family
and he is married and he had 6 kids, so to support his family he could not quit this job i.e. at
hotel, hence he could not quit his friends at the hotel which act as perpetuating factor for him.
The client reported that he had good insight of his problem as he mentioned that he knows that
drinking and drug abuse is not good for him as well as well for his family. So, he feels motivated
and hopeful that he will be succeeded in quitting drugs and dinking. However, he had good
support from his family specially from his older brother and wife. So, his family act as a
protective factor for him.

Proposed Treatment

After considering the complaints or problems reported by the client and by after clinically
assessing him, the client should go to Detoxification, Behavioral therapies and medication.

As the client is already under all of these treatments, in Ali Rehabilitation center.

Conclusion

Conclusively, the combination of different assessments suggest that the client had moderate level
depression, low anxiety and severe level of stress. Mr. U had no symptoms of maladaptive
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behavior tendencies, disturbance in language and memory functioning, pathology or problem in

emotional development.

After clinically assessing Mr. U, it can be concluded that he is going from these problems
“numbness, wobbliness in legs, unable to relax, hands trembling, shaky hands, aggressiveness,
self-criticism and dizziness” which can be the symptoms of detoxification and alcohol
withdrawal. Other than these problems he is not facing any serious problem which can be the
matter of concern like suicidal thoughts/behavior or any other cognitive or mental issue. As the
client is self-motivated, has a good insight of his problem and had full support from his family, it
seems that Mr. U can be fully recovered in few months if he kept on motivating himself and
improving, like he is doing now.