SUBSTANCE-RELATED DISORDERS

Drug addiction, also called substance use disorder, is a disease that affects a person's brain

and behavior and leads to an inability to control the use of a legal or illegal drug or medicine.

Substances such as alcohol, marijuana and nicotine also are considered drugs.

The substance-related disorders encompass 10 separate classes of drugs: alcohol;

caffeine; cannabis; hallucinogens (with separate categories for phencyclidine [or similarly

acting arylcyclohexylamines] and other hallucinogens); inhalants; opioids; sedatives,

hypnotics, and anxiolytics; stimulants (amphetamine-type substances, cocaine, and other

stimulants); tobacco; and other (or unknown) substances. All drugs that are taken in excess

have in common direct activation of the brain reward system, which is involved in the

reinforcement of behaviors and the production of memories.

The substance-related disorders are divided into two groups:

1. Substance Use Disorders and

2. Substance-Induced Disorders.

Substance Use Disorder

The essential feature of a substance use disorder is a cluster of cognitive,

behavioral, and physiological symptoms indicating that the individual continues using the

substance despite significant substance-related problems. An important characteristic of

substance use disorders is an underlying change in brain circuits that may persist beyond

detoxification, particularly in individuals with severe disorders. The behavioral effects of

these brain changes may be exhibited in the repeated relapses and intense drug craving when

the individuals are exposed to drug-related stimuli.

1
 The diagnosis of a substance use disorder is based on a pathological pattern of

behaviors related to use of the substance. To assist with organization, criteria can be

considered to fit within overall groupings of impaired control, social impairment, risky use,

and pharmacological criteria.

Impaired Control. The individual may take the substance in larger amounts or over a

longer period than was originally intended (Criterion 1). The individual may express a

persistent desire to cut down or regulate substance use and may report multiple unsuccessful

efforts to decrease or discontinue use (Criterion 2). The individual may spend a great deal of

time obtaining the substance, using the substance, or recovering from its effects (Criterion 3).

Craving (Criterion 4) is manifested by an intense desire or urge for the drug that

may occur at any time but is more likely when in an environment where the drug previously

was obtained or used.

Social Impairment. It is the second grouping of criteria (Criteria 5–7). Recurrent

substance use may result in a failure to fulfill major role obligations at work, school, or home

(Criterion 5). The individual may continue substance use despite having persistent or

recurrent social or interpersonal problems caused or exacerbated by the effects of the

substance (Criterion 6).

Important social, occupational, or recreational activities may be given up or reduced

because of substance use (Criterion 7).

Risky Use. Risky use of the substance is the third grouping of criteria (Criteria 8–9).This

may take the form of recurrent substance use in situations in which it is physically hazardous

(Criterion 8). The individual may continue substance use despite knowledge of having a

2
persistent or recurrent physical or psychological problem that is likely to have been caused or

exacerbated by the substance (Criterion 9).

Pharmacological criteria are the final grouping (Criteria 10 and 11). Tolerance

(Criterion 10). It is signaled by requiring a markedly increased dose of the substance to

achieve the desired effect or a markedly reduced effect when the usual dose is consumed. The

degree to which tolerance develops varies greatly across different individuals as well as

across substances and may involve a variety of central nervous system effects.

Withdrawal (Criterion 11). It is a syndrome that occurs when blood or tissue

concentrations of a substance decline in an individual who had maintained prolonged heavy

use of the substance. After developing withdrawal symptoms, the individual is likely to

consume the substance to relieve the symptoms. Withdrawal symptoms vary greatly across

the classes of substances, and separate criteria sets for withdrawal are provided for the drug

classes.

Substance-Induced Disorder

Substance Induced Disorder includes Substance Intoxication and Substance Withdrawal.

Substance Intoxication. Substance intoxication is common among those with a

substance use disorder but also occurs frequently in individuals without a substance use

disorder. This category does not apply to tobacco. The most common changes in intoxication

involve disturbances of perception, wakefulness, attention, thinking, judgment, psychomotor

behavior, and interpersonal behavior.

Intoxication may sometimes persist beyond the time when the substance is detectable

in the body. This may be due to enduring central nervous system effects, the recovery of

which takes longer than the time for elimination of the substance.

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Substance Withdrawal. “Withdrawal is also known as detoxification or detox. It's when

you quit, or cut back, on using alcohol or other drugs.” Drug withdrawal is a physiological

response to the sudden quitting or slowing of use of a substance to which the body has grown

dependent on.

When someone regularly drinks alcohol or uses certain drugs, their brain may begin

to adjust to the presence of these substances.

Tobacco Use Disorder

Diagnostic Criteria

A. A problematic pattern of tobacco use leading to clinically significant impairment or

distress, as manifested by at least two of the following, occurring within a 12-month period:

1. Tobacco is often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control tobacco use.

3. A great deal of time is spent in activities necessary to obtain or use tobacco.

4. Craving, or a strong desire or urge to use tobacco.

5. Recurrent tobacco use resulting in a failure to fulfill major role obligations at work, school,

or home (e.g., interference with work).

6. Continued tobacco use despite having persistent or recurrent social or interpersonal

problems caused or exacerbated by the effects of tobacco (e.g., arguments with others about

tobacco use).

7. Important social, occupational, or recreational activities are given up or reduced because

of tobacco use.

8. Recurrent tobacco use in situations in which it is physically hazardous (e.g., smoking in

bed).

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9. Tobacco use is continued despite knowledge of having a persistent or recurrent physical or

psychological problem that is likely to have been caused or exacerbated by tobacco.

10. Tolerance, as defined by either of the following:

a. A need for markedly increased amounts of tobacco to achieve the desired effect.

b. A markedly diminished effect with continued use of the same amount of tobacco.

11. Withdrawal, as manifested by either of the following:

a. The characteristic withdrawal syndrome for tobacco (refer to Criteria A and B of

the criteria set for tobacco withdrawal).

b. Tobacco (or a closely related substance, such as nicotine) is taken to relieve or

avoid withdrawal symptoms.

Specify current severity:

305.1 (Z72.0) Mild: Presence of 2–3 symptoms.

305.1 (F17.200) Moderate: Presence of 4–5 symptoms.

305.1 (F17.200) Severe: Presence of 6 or more symptoms.

Comorbidity

Comorbidity is the presence of one or more additional disorders co-occurring with the

primary disease or disorder, or the effect of such additional disorders or diseases. The most

common medical diseases from smoking are cardiovascular illnesses, chronic obstructive

pulmonary disease, and cancers. Smoking also increases perinatal problems, such as low birth

weight and miscarriage. The most common psychiatric comorbidities are alcohol/substance,

depressive, bipolar, anxiety, personality, and attention-deficit/hyperactivity disorders. In

5
individuals with current tobacco use disorder, the prevalence of current alcohol, and drug,

anxiety, depressive, bipolar, and personality disorders ranges from 22% to 32%.

Tobacco Withdrawal

Diagnostic Criteria

A. Daily use of tobacco for at least several weeks.

B. Abrupt cessation of tobacco use, or reduction in the amount of tobacco used, followed

within 24 hours by four (or more) of the following signs or symptoms:

1. Irritability, frustration, or anger.

2. Anxiety.

3. Difficulty concentrating.

4. Increased appetite.

5. Restlessness.

6. Depressed mood.

7. Insomnia.

C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

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D. The signs or symptoms are not attributed to another medical condition and are not better

explained by another mental disorder, including intoxication or withdrawal from another

substance.

Differential Diagnose

The symptoms of tobacco withdrawal overlap with those of other substance

withdrawal syndromes (e.g., alcohol withdrawal; sedative, hypnotic, or anxiolytic

withdrawal; stimulant withdrawal; caffeine withdrawal; opioid withdrawal); caffeine

intoxication; anxiety, depressive, bipolar, and sleep disorders; and medication-induced

akathisia.

Cannabis Use Disorder

Cannabis, also known as marijuana among other names, is a psychoactive drug from

the Cannabis plant. Native to Central and South Asia, the cannabis plant has been used as a

drug for both recreational and entheogenic purposes and in various traditional medicines for

centuries. Tetrahydrocannabinol (THC) is the main psychoactive component of cannabis,

which is one of the 483 known compounds in the plant, including at least 65

other cannabinoids, including cannabidiol (CBD). Cannabis can be used by smoking.

Marijuana refers to the dried leaves, flowers, stems, and seeds from the Cannabis

sativa or Cannabis indica plant. The plant contains the mind-altering chemical THC and other

similar compounds. Extracts can also be made from the cannabis plant.

Diagnostic Criteria

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A problematic pattern of cannabis use leading to clinically significant impairment or distress,

as manifested by at least two of the following, occurring within a 12-month period:

1. Cannabis is often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control cannabis use.

3. A great deal of time is spent in activities necessary to obtain cannabis, use cannabis, or

recover from its effects.

4. Craving, or a strong desire or urge to use cannabis.

5. Recurrent cannabis use resulting in a failure to fulfill major role obligations at work,

school, or home.

6. Continued cannabis use despite having persistent or recurrent social or interpersonal

problems caused or exacerbated by the effects of cannabis.

7. Important social, occupational, or recreational activities are given up or reduced because of

cannabis use.

8. Recurrent cannabis use in situations in which it is physically hazardous.

9. Cannabis use is continued despite knowledge of having a persistent or recurrent physical

or psychological problem that is likely to have been caused or exacerbated by cannabis.

10. Tolerance, as defined by either of the following:

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a. A need for markedly increased amounts of cannabis to achieve intoxication or desired

effect.

b. Markedly diminished effect with continued use of the same amount of cannabis.

11. Withdrawal, as manifested by either of the following:

a. The characteristic withdrawal syndrome for cannabis (refer to Criteria A and B of the

criteria set for cannabis withdrawal, pp. 517–518).

b. Cannabis (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.

Specify current severity:

305.20 (F12.10) Mild: Presence of 2–3 symptoms.

304.30 (F12.20) Moderate: Presence of 4–5 symptoms.

304.30 (F12.20) Severe: Presence of 6 or more symptoms.

Comorbidity.

Cannabis has been commonly thought of as a “gateway” drug because individuals who

frequently use cannabis have a much greater lifetime probability than nonusers of using what

are commonly considered more dangerous substances, like opioids or cocaine. Cannabis use

and cannabis use disorder are highly comorbid with other substance use disorders. Cannabis

use has been associated with poorer life satisfaction; increased mental health treatment and

hospitalization; and higher rates of depression, anxiety disorders, suicide attempts, and

9
conduct disorder. Individuals with past-year or lifetime cannabis use disorder have high rates

of alcohol use disorder (greater than 50%) and tobacco use disorder (53%).

Rates of other substance use disorders are also likely to be high among individuals

with cannabis use disorder. Among those seeking treatment for a cannabis use disorder, 74%

report problematic use of a secondary or tertiary substance: alcohol (40%), cocaine (12%),

methamphetamine (6%), and heroin or other opiates (2%). Among those younger than 18

years, 61% reported problematic use of a secondary substance: alcohol (48%), cocaine (4%),

methamphetamine (2%), and heroin or other opiates (2%).

Cannabis Withdrawal

Diagnostic Criteria

A. Cessation of cannabis use that has been heavy and prolonged (i.e., usually daily or almost

daily use over a period of at least a few months).

B. Three (or more) of the following signs and symptoms develop within approximately 1

week after Criterion A:

1. Irritability, anger, or aggression.

2. Nervousness or anxiety.

3. Sleep difficulty (e.g., insomnia, disturbing dreams).

4. Decreased appetite or weight loss.

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5. Restlessness.

6. Depressed mood.

7. At least one of the following physical symptoms causing significant discomfort: abdominal

pain, shakiness/tremors, sweating, fever, chills, or headache.

C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

D. The signs or symptoms are not attributable to another medical condition and are not better

explained by another mental disorder, including intoxication or withdrawal from another

substance.

Differential Diagnosis

Schizophrenia and other mental disorders: Some of the effects of phencyclidine and

related substance use may resemble symptoms of other psychiatric disorders, such as

psychosis (schizophrenia), low mood (major depressive disorder); violent aggressive

behaviors (conduct disorder, antisocial personality disorder).

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Opioid-Related Disorder

Diagnostic Criteria

A. A problematic pattern of opioid use leading to clinically significant impairment or distress,

as manifested by at least two of the following, occurring within a 12-month period:

1. Opioids are often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.

3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or

recover from its effects.

4. Craving, or a strong desire or urge to use opioids.

5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school,

or home.

6. Continued opioid use despite having persistent or recurrent social or interpersonal

problems caused or exacerbated by the effects of opioids.

7. Important social, occupational, or recreational activities are given up or reduced because of

opioid use.

8. Recurrent opioid use in situations in which it is physically hazardous.

9. Continued opioid use despite knowledge of having a persistent or recurrent physical or

psychological problem that is likely to have been caused or exacerbated by the substance.

10. Tolerance, as defined by either of the following:

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 a. A need for markedly increased amounts of opioids to achieve intoxication or desired

effect

b. A markedly diminished effect with continued use of the same amount of an opioid.

Note: This criterion is not considered to be met for those taking opioids solely under

appropriate medical supervision.

11. Withdrawal, as manifested by either of the following:

a. The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the

criteria set for opioid withdrawal, pp. 547–548).

b. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal

symptoms.

Note: This criterion is not considered to be met for those individuals taking opioids solely

under appropriate medical supervision.

Specify current severity:

 305.50 (F11.10) Mild: Presence of 2–3 symptoms.

 304.00 (F11.20) Moderate: Presence of 4–5 symptoms.

 304.00 (F11.20) Severe: Presence of 6 or more symptoms.

Comorbidity

The most common medical conditions associated with opioid use disorder are viral

(e.g., HIV, hepatitis C virus) and bacterial infections, particularly among users of opioids

by injection. These infections are less common in opioid use disorder with prescription

opioids.

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 Opioid use disorder is often associated with other substance use disorders,

especially those involving tobacco, alcohol, cannabis, stimulants, and benzodiazepines,

which are often taken to reduce symptoms of opioid withdrawal or craving for opioids, or

to enhance the effects of administered opioids. Individuals with opioid use disorder are at

risk for the development of mild to moderate depression that meets symptomatic and

duration criteria for persistent depressive disorder (dysthymia) or, in some cases, for

major depressive disorder. These symptoms may represent an opioid-induced depressive

disorder or an exacerbation of a preexisting primary depressive disorder.

Periods of depression are especially common during chronic intoxication or in

association with physical or psychosocial stressors that are related to the opioid use

disorder. Insomnia is common, especially during withdrawal. Antisocial personality

disorder is much more common in individuals with opioid use disorder than in the general

population.

Differential Diagnosis

Opioid-induced mental disorders. Opioid-induced disorders occur

frequently in individuals with opioid use disorder. Opioid-induced disorders may be

characterized by symptoms (e.g., depressed mood) that resemble primary mental disorders

(e.g., persistent depressive disorder [dysthymia] vs. opioid-induced depressive disorder, with

depressive features, with onset during intoxication). Opioids are less likely to produce

symptoms of mental disturbance than are most other drugs of abuse. Opioid intoxication and

opioid withdrawal are distinguished from the other opioid-induced disorders (e.g., opioid-

induced depressive disorder, with onset during intoxication) because the symptoms in these

latter disorders predominate the clinical presentation and are severe enough to warrant

independent clinical attention.

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Opioid Withdrawal

A. Presence of either of the following:

1. Cessation of (or reduction in) opioid use that has been heavy and prolonged (i.e., several

weeks or longer).

2. Administration of an opioid antagonist after a period of opioid use.

B. Three (or more) of the following developing within minutes to several days after Criterion

A:

1. Dysphoric mood.

2. Nausea or vomiting.

3. Muscle aches.

4. Lacrimation or rhinorrhea.

5. Pupillary dilation, sweating.

C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

D. The signs or symptoms are not attributable to another medical condition and are not better

explained by another mental disorder, including intoxication or withdrawal from another

substance.

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Case Identification

Duration of Session:

The sessions were conducted from October 17th; 2022to October 19th, 2022. Each

Session was approximately 1 and half hours span.

Referral

Client stated that he began treatment at Nijjat Trust Rehabilitation Centre in Rawalpindi

Six years ago. He was discharged after five months and sent to Saudi Arabia by his father. He

came from Saudi Arabia after four years to get married. One year later, his father passed

away, which caused him to abuse drugs and his elder brother admitted him to Nijjat Trust

Rehabilitation Centre, where he is still admitted.

Identifying Data

Name: X, Y, Z

Sex: Male

Age: 27 Years

Education: Matric

Occupation: Rickshaw driver

Monthly Income: 20,000

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Father’s Name: Gulaam Muhammad

Mother’s Name: Rukhsana

Father: Alive --------------- Dead-------------

Mother: Alive ----------------Dead----------------

Father’s Education: F.S.C

Mother’s Education: B.A

Father’s Occupation: Leftinent General

Mother’s Occupation: Teacher

No. of Sibling: Seven

No. of Brothers: Four

No. of Sisters: Three

Step Relation: Nil

Marital Status: Married

No. of Children: One boy

Birth Order: Client is 2nd in Sibling of 7

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‫‪Place of Birth:‬‬ ‫‪Kohat Hospital‬‬

‫‪Place of Residence:‬‬ ‫‪Chakwal‬‬

‫‪Family System:‬‬ ‫‪Joint Family System‬‬

‫‪Referral:‬‬ ‫‪Elder Brother‬‬

‫‪Religion:‬‬ ‫‪Islam‬‬

‫‪Informant:‬‬ ‫‪Staff of Rehabilitation Centre‬‬

‫‪Presenting Complaints‬‬

‫‪By Client:‬‬

‫میرے سر میں درد ہے‪ .‬مجھے اکثر ہائی بلڈ پریشر بھی ہوتا ہے۔ میں بہت تھکا ہوا محسوس کر رہا ہوں۔ مجھے‬

‫بہت غصہ آتا ہے‪ ،‬مجھے بھوک نہیں لگتی۔ مجھے نیند نہیں آتی۔ میرا منہ اور گال زیادہ تر خشک رہتا ہے۔ مجھے‬

‫پچھلے تین دنوں سے بخار ہے۔ کبھی کبھی میں ایک ہی وقت میں بہت خوش اور اداس ہوتا ہوں۔ جب میں کوئی بھی‬

‫کام شروع کرتا ہوں تو میری ٹانگیں اور ہاتھ بے ح س ہو جاتے ہیں مجھے بہت دکھ ہوتا ہے میں اپنے ہر کام میں‬

‫ناکام رہا ہوں۔ میں لوگوں کی آوازیں سنتا ہوں۔ میرے والد میرے سامنے بیٹھتے ہیں اور مجھ سے باتیں کرتے ہیں‪.‬‬

‫میرے والد روز خواب میں آتے ہیں۔ میں تنہا محسوس کرتا ہوں۔میں چڑچڑا محسوس کرتا ہوں۔‬

‫‪18‬‬
By Informant:

When the client arrived for treatment, he displayed inappropriate behavior. He was

easily irritated or agitated by mild stimuli during his first days in the hospital. He attempted

to kill another patient and to commit suicide. He once cut his own body and tried to run to the

hospital. On the first few days, he complained that he couldn't sleep and that if he didn't take

the drug, he felt pain in his body, weakness, tingling in his hand, and water coming from his

eyes and nose. His condition has changed. He is calm, humble, and cooperative, and he tries

to listen to the doctor. His annoyance ended.

Symptoms

Headache ‫میرے سر میں درد ہے‬

I frequently have high blood pressure. ‫مجھے اکثر ہائی بلڈ پریشر بھی ہوتا ہے‬

Fatigue ‫میں بہت تھکا ہوا محسوس کر رہا ہوں‬

Aggressive Outbursts . ‫مجھے بہت غصہ آتا ہے‬

Loss of Appetites . ‫مجھے بھوک نہیں لگتی‬

Insomnia .‫مجھے نیند نہیں آتی‬

Dryness of mouth and Throat . ‫میرا منہ اور گال زیادہ تر خشک رہتا ہے‬

Fever from 3 days . ‫مجھے پچھلے تین دنوں سے بخار ہے‬

19
Fluctuation of Mood . ‫کبھی کبھی میں ایک ہی وقت میں بہت خوش اور اداس ہوتا ہوں‬

Tingling in hand and feet ‫جب میں کوئی بھی کام شروع کرتا ہوں تو میری ٹانگیں اور ہاتھ بے حس ہو جاتے‬

. ‫ہیں‬

Feeling Alone ‫میں تنہا محسوس کرتا ہوں‬

Irritability ‫میں چڑچڑا محسوس کرتا ہوں۔‬

When I start work I feel hopeless about work ‫مجھے بہت دکھ ہوتا ہے میں اپنے ہر کام میں ناکام رہا ہوں‬

Auditory Hallucination ‫میں لوگوں کی آوازیں سنتا ہوں‬

My father speaks with me on a daily basis, but he is no longer alive (Visual Hallucination)

‫میرے والد میرے سامنے بیٹھتے ہیں اور مجھ سے باتیں کرتے ہیں‬

Disturbing reamD ‫میرے والد روز خواب میں آتے ہیں‬

Behavioral Observation

Session 1: The client was sitting in an awkward position. He displayed unusual

behavior at first. When I asked him his name, he gave me a strange look. He was staring at

the door and constantly staring at me. When I told him about his marital life, he became

irritated and frustrated. Throughout the session, his hand was shaking and he rotated his chair

repeatedly. He was puzzled and repeated her words over and over. Throughout the session, he

20
appears tired and defends himself and his behavior. The client frequently rubbed his hands,

face, and hair. The client made a no eye contact while looking down.

Session 2: The client was in a relatively comfortable situation, but when questioned,

he displayed anxious behavior, including frequent leg shaking and rubbing of the hand, face,

and hair. Throughout the session, eye contact was rare.

Session 3: In the third session, the client became largely stable. Unlike the previous

session, he did not react anxiously. The body's impression and posture were still largely

stable. Even after the development of the repo building and when the client was feeling

relaxed and ready to share his feelings and experiences, the leg shaking was still noticeable

with the same intensity. The client maintained a formal eye contact.

Personal History

In 1994, the client was born in Kohat. He recalled his early development, saying that

he was sharp and active. He enjoyed playing video games. He took part in all activities and

enjoyed playing cricket and badminton. His mother informed him that he began to walk at the

age of seven months and ran throughout the house at the age of one year. His father was a

laftinent general in the Army and well-educated. Everyone admired and praised his father

because he was so strong and responsible in his duties, he claimed. All of my siblings

received training from my father, and although everyone else thought our home environment

was ideal, we did not.

His mom worked as a teacher. His childhood was good, but there weren't many really

bad things that happened. He claimed to be his parents' most beloved son. He has 7 siblings.

There are three brothers and four sisters. He was the most well-cared-for kid. He describes

21
his father as being extremely angry, emotionless, powerful, and sticking to his morals, while

his mother is described as a very loving, innocent, gentle, and loving woman. His father and

Mother nature frequently argued because they thought very differently from one another and

were incompatible with one another. When his mother did not pay attention to him, his father

would scold her. His mother was not happy during their entire marriage due to his father’s

behavior.

He stated, "One of the most painful moments in my life was when my mother cried

all the time and my father didn't care why she was crying." He didn't talk to each other for a

month, and because of my father's bad behavior, my mother went to her father's house. We

siblings were alone without my mother. His father looked after them, but he always needed a

mother, and after two months, his mother came to us because we couldn't eat without her. His

mother was in grief until his father died because he did not care for his mother, and this was

not a happy marriage for the parents. His sibling was unaffected by the problem with their

parents' relationship. However, he and his sisters were the most affected, and he was

extremely sensitive. However, he stated that he loves both his mother and father, but that he

has disagreements and clashes with his father.

He describes his school life as being filled with naughtiness and fights with his

classmates, but he also describes a lot of suffering in school. His father transferred to another

city, so his school changed over the years, and he faced difficulties in every phase of school.

He had difficulty making friends, so he had no friends who listened to him. In seventh grade,

he read in one school and made one friend throughout the year. Their bond was extremely

strong and deep however, his friends ruin his life. His studies were uninteresting, and his

father hoped that he would join the army after the 12th grade. However, he was unable to

study, which is why his father was dissatisfied with him. He was depressed as a result of his

22
father's bad behavior. He claimed to have tried to study, but I was unable to do so. His

friend's home was a financial issue that he frequently worried about, and he smoked

cigarettes and cannabis. We discussed every issue with one another. The client was worried,

and his friend advised him to take drugs because they would make him feel better. He tried

cigarettes for the first time when he was 14 years old, and cigarettes became a habit for him.

When the teacher found out about his friend's drug use His friend was expelled from school.

He was lonely and depressed, and after a while he became interested in one girl who went to

the same school as him and studied with him. He had an emotional connection with her and

shared a problem with her. He proposed to her one day and she said yes, not knowing he was

on drugs. She left him after revealing he was using drugs. He consumed an excessive amount

of cannabis and cigarette. After completing his Matric, he was forced to join the army by his

father, but after a month, he escaped to the camp because he needed drugs. His family moved

to Rawalpindi after his father retired.

Client stated that he began using cannabis more frequently when he was 18 years old.

He and his brother worked on the shop. His condition remained constant after consuming

cannabis, and he was in the same situation throughout the day. He stated that his father was

concerned about his health. When his father saw the client's condition, he became suspicious.

He caught him red-handed drugging. His father says to the client for the first time, "I'm sorry

you're my son." After today, don't call me father. His father was admitted to Nijjat Trust

Rawalpindi at the age of 21. He claimed that when he did not take the drug, he experienced

pain throughout his body. He was discharged after 5 months. He abandoned the drug.

The client described his journey to Saudi Arabia. His father had sent him to Saudi

Arabia. He was working on the restaurants. He stated that the four years I spent there were

among the best of my life. He stated that he loves the girl and that he misses her a lot. His

23
parents desired to marry him, but he did not want to get married life. After forcing his parents

to marry, he returned to Saudi Arabia after four years. During the first month of their

marriage, his wife was loving and caring. She attended to the client's every need. He met his

old friend one day. His friend compelled him to attend the gathering. His friend continued to

use cannabis on a regular basis.

The client described his wife and mother as being cruel to each other. His wife wants

him to be separated from his parents, but the client adores his parents. He did not want to be

separated from his parent. But he also did not abandon her because she is the mother of his

child. He was irritated with his wife, but he was obligated to stay with her for the sake of his

son. He claimed that after his wife realized that he was using drugs, she stopped caring for

him. She would constantly make fun of his inability to get well. She didn't like me very

much. Our son is the reason we share a home. She treated me this way because I am

deserving of it. She's always right when she says I can't handle relationships.

He stated that he wished to die because of the circumstances at home. His relapsing

symptoms returned. He used cannabis again to use the peace at the age of 25. He and his

friend took drugs after offering Namaz e jumma. His wife and parents were unaware that he

had restarted drug use.

He claimed that his wife noticed the injection one day. She informed his parents

about his drug use. His father is so upset that he did not speak to him. He stated, "One of the

worst days of my life was when my father told me before death that you are the most beloved

son in all my children. When you left the army, I was upset, but today you died me before my

death, and after today, you do not come in front of me”. After two days, he died in my hand,

24
and I was helpless at that moment and I couldn’t do anything. It was a pain that still hurts me

as much today as it did the day my father died.

He talked about how everyone always admired his older brother because he always

looked out for the whole family, and because of his brother's responsibility, his parents were

always impressed with him. The client claims that he feels his older brother is better than him

in all areas and that as a result, he has given up on many activities.

He describe about his dream. He stated that his father still spoke to him and that he

sat in front of him. He did not forgive him, and he could not sleep for an hour because he saw

his father in every dream. He appeared in front of him while he was sleeping. But his father

also told him in a dream that if he helped his family financially, he would forgive him.

The client became depressed. He claimed that he saw his father in every dream. He

was angry with him and refused to speak to him. He said, “But now he talks in front of me

and says he will not forgive me, and I daily apologize to him, but he does not listen to me”.

The client attempted suicide, but his elder brother aided and saved him. He abused cannabis

and powder after the death of his father, and his elder brother and sister, who adored him,

admitted him to the Nijjat Trust in Rawalpindi, and his siblings also financially supported his

family. He has been here for 17 days.

History of Present Illness

During his childhood, the client had a sensitive, careful, and sharp personality. At the

age of one year, he was able to walk and run around the house. His childhood was difficult

due to his parents' tense relationship. For the very first time Due to the parent's relationship,

he was involved in cigarette at the age of 14 and used 1 pack of cigarette per day. He began

25
using cannabis at the age of 15 out of curiosity. When he was 18, he began using cannabis

excessively after a girl he loved left him. Hallucination has been reported. The majority of the

patient's complaints concerned his physical health.

Pre-Morbid Personality

Up until childhood, the client was a loving, caring child. He was the type of person

who preferred to be with one friend, who also changed him. With his father, he had extremely

tense and troubled relationships. Compared to his siblings, he used to be a lot more sensitive.

At the age of 7, he underwent surgery for jaundice. After their father passing, the client had a

very depressed attitude toward their father.

The client is unable to care for his family. Before his father's death, the client had

trust in him, and now he has trust in her older brother. He never made the right decisions, and

they were always the wrong ones. The client was afraid of dying a wicked death. He

primarily exhibited irritated, depressed, and ill-feeling behavior. He offers prayer and has a

deep understanding of the Qur'an. He was previously interested in dramas and movies, but he

is no longer interested in anything.

He desired to be alone. He has a fear of people. He prefers quiet people and dislikes

loud people. He was convinced that he had not fulfilled his father's dream. He also expresses

strong beliefs about the future, stating that one day he will become a businessman and care

for his family. He enjoyed cricket and badminton, but not after taking drugs.

The irritable and aggressive attitude was observed to be experienced by him since

the age of 14, when he first tried cigarettes. Gradually, his aggressive behavior grew up.

When asked questions about areas of his conflict, it can be assumed that he is defensive in

26
nature due to his previous experience. However, in later sessions, the client became more

open and comfortable, while remaining defensive about his family and marital problems.

Onset of Illness

7th Years Old Parental marital issue, Jaundice at the age of 7 year old.

14th Years of age For the first time, he used a cigarette to keep the peace. He smoked

one pack of cigarettes per day.

15 Years of age He used cannabis to satisfy his curiosity. He primarily used cannabis

four times in day.

Use Cannabis more frequently.

18 Years of age

21 Year Old He was admitted to the Nijjat Trust in Rawalpindi. He was

discharge after four months.

25th Year of age Relapses began again when he was 25 years old, and he began using

opioids but he used cannabis more frequently.

27th Years of age He is now on Nijjat Trust Rawalpindi for treatment.

27
Formal assessments

Formal assessments consist primarily of standardized tests or performance review

that has been validated and tested using samples of intended test groups. They have specific

test administration and scoring procedures, as well as credential or training requirements for

test administrators. Test scores may be criterion-based (based on knowledge or ability in a

specific academic or vocational area) or norm-referenced (based on a comparison to the

sample of the test-taker peers) (NCDW, 2002).

The following tests are used to assess client’s problems, their intensity and personality

through standards.

1. Mental Status Examination (MSE)

2. Beck Depression Inventory (BDI)

3. Rotter’s Incomplete Sentence Blank (RISB)

Mental Status Examination (MSE)

The Mental Status Examination was originally modeled after the physical medical

exam; just as the physical medical exam is designed to review the major organ systems, the

medical status exam reviews the major systems of psychiatric functioning (appearance,

cognitive function, insight, etc.). Since its introduction into American psychiatry by Adolf

Meyer in 1902, it has become the mainstay of patient evaluation in most psychiatric settings.

28
Most psychiatrists consider it as essential to their practice as the physical examination is in

general medicine (Rodenhauser &Formal, as cited in Marnat, 1997).

B.) Appearance, attitude and activity.

Appearance

 Outlook of patient: The patient's overall outlook was decent, but he was unshaven bread.

His weight was emaciated. On his arms, he had scars.

 Level of consciousness: The client was attentive in some questions, but drowsy in others,

and his expression of sleepiness was clearly visible throughout the session

 Apparent Age: He seems to be of 35 but originally he was of 27.

 Position/Posture: The client was sitting in an uncomfortable position, shaking his legs

very quickly, and hand movement was observed to be increased in areas of questioning or

conflict e.g. RISB.

 Attire/Grooming: Client’s overall appearance was organized and proper. He was well

dressed.

 Abnormal Physical Trait: Nil

 Eye Contact: Session 1: no eye contact by client was observed.

Session 2: rare eye contact during conversations was observed.

Session 3: The client maintained a formal rare eye contact.

 Attitude (degree & type of cooperative and resistance): The client's attitude

was open, attentive, and cooperative, but in some areas, the client displayed defensive

29
 and evasive responses while performing the RISB test with reduced intensity. The

overall attitude was more open and cooperative.

 Activity (Physical movement)

Voluntary localized movement by client was shown. The client demonstrated

actions such as leg shaking, hair, face, and hand rubbing.

Involuntary Movement: For a short moment, hand trembling was observed during a specific

movement.

Tics (Vocal/Motor): Nil

Compulsion: The patient repeatedly placed his hand on the table and twisted and untwisted

his hair.

C.) Mood & Affect.

Mood (Person’s predominant mood). The mood of client was normal with mild depression

and self-deprecating humor shown on question or certain areas of discussion. The client

showed anhedonic mood.

Affect (external manifestation of emotion &feelings).

 Types of Affects (Happy, sad, Apprehensive and confused): During conversation, the

client showed a depressed mood in some areas but a normal mood in others. He

becomes unsure in his behavior, especially when it comes to familial and social

interactions.

30
  Reactivity: The defensiveness was most noticeable in familial and impulsive areas. The

client's reactivity and effect were inappropriate. He laughed at times and then appeared

depressed when he told about his father.

 Mobility (Change of Affect/mood shift for reaction): The client's mood changed as his

conversation transitioned from a normal to a happy or sad event.

 Mood (Anhedonic , Grieving, Dysphoric, Depressed): Client reported that he did not

enjoy anything once he enjoyed. When the client spoke about his negative experiences

and the death of his father, he displayed grief-related depression and dysphoria.

Client showed irritable and angry behavior when he talked about his old friend.

D.) Speech and Language

 Fluency: The overall client's speech was slow.

 Comprehension: The client showed an incorrect understanding of the direction he was

given. For the first two trials, he was unable to respond accurately to any direction.

 Repetition: The client repeated a few words in the description. In the tests that revealed

the unconscious, phrases were more visible. For instance, Rotter Incomplete Sentence

Blank Test.

 Writing: the writing of client is readable but not in a proper way.

 Prosody (Intonation, Speech, rate of conversation): Except for questions about family

or the future, the conversation rate was slow and the intonation was normal.

D.)Thought Process, Thought Content &Perception:

Thought Process. Peculiar thought process (Neologism [Naming], perseveration

[Repetition], Blocking [Resistance], Tangentiality: Thought perseverance was observed in

the client's conversation about his previous experience and his relationship with his father.

31
Thought Blocking was observed during his conversation about his bad experiences with his

friend. Client demonstrated tangentiality by responding to answers that were completely

unrelated at times.

 Delusion: Infidelity Client reported his wife has no feeling toward him.

 Overvalued Ideas: Throughout the sessions ideas about the client's negative

environment, drug use, health, memories of his father and the girl, and desire to leave

rehabilitation were observed.

 Obsession: Nil

 Preoccupation (Pre entangled thoughts): Client was preoccupied with his father's and the

girl's isolation, as well as his negative past experience and relapsed.

 Suicidal Ideation: After his father died, the client attempted suicide, but his elder brother

saved him.

 Phobias (Acrophobia, Xenophobia and Social Phobia): The client stated that he was

terrified of heights. He wanted to do things alone and avoid people and social

interaction. He also stated that he was afraid of foreigners in Saudi Arabia, where people

hate each other due to differences in culture and racism.

F.) Perceptual Abnormalities.

 Hallucination (Auditory Hallucination &Visual Hallucination): Client stated that when

he was a child, he heard voices of strange people who tried to kill him.

The client stated that even after his father passed away, he continued to speak with

him every day.

32
G.) Cognition.

 Orientation: Orientation of time, place and person were proper in client.

H.) Attention and Concentration.

 Registration (Capacity to immediately repeat live info): During a few questions in the

session, the client was less focused and more often distracted, but overall, he paid

attention well. He was unable to correctly repeat seven digits. For instance, only 695837

of the 6958372 clients could repeat...

 Memory (Short Term/Long Term): The long-term memory and short memory of the

client was good.

I.)Insight and Judgment:

 Insight: Insight is appropriate for the client in some situations because he can tell the

difference between right and wrong, ethical and unethical behavior. However, the client

is also aware that what he perceives as reality may not actually exist.

 Judgment: The client's overall psychological health is very concerning because he has

an aggressive self-concept in relation to certain aspects of his life.

2. Beck Depression Inventory (BDI). The Beck Depression Inventory (BDI, BDI-

1A, BDI-II), created by Aaron T. Beck, is a 21-question multiple-choice self- report

inventory, one of the most widely instruments for meaning the severity of depression. In

development marked a shift among health care professionals, who had until then viewed

depression from a psychodynamic perspective, instead of it being rooted in the patient’s

own thoughts.

33
 In its current version the questionnaire is designed for individual aged 13

and over, and is composed of items relating to symptoms of depression such as

hopelessness and irritability, cognitions such as guilt or feeling of being punished, as well

as physical symptoms such as fatigue, weight loss, and lack of interest in sex (Beck,

1972).

Scoring.

Total Score/Cutoff score: 63

Subject Score: 43 score

The client's inventory score of 43 indicates that he is experiencing severe

depression. He received high scores for his depressed mood, his family and social

relationships, his sense of regret, his level of interest, and his concern for his health. His

significant anomalies are apparent from the responses to items 1, 2, 6, 8, 9, 10, 16, and

20.

Interpretation: The result shows that subject obtained a score of 43and total score is 63.

The result indicates that the subject is suffering from severe depression. Client showed some

responses that are deviate from normality i.e. 1, 2, 6,8,9,10,16 and 20.

Item no. 1

I am so sad and unhappy that I can’t stand it. ‫میں اتنا اداس اور ناخوش ہوں کہ میں اسے برداشت نہیں کر‬

.‫سکتا‬

34
 Client stated that he was depressed about his future and his health. He has

grieved so much that he is unable to move on.

Item no.3

I feel I am a complete failure as a person. ‫مجھے لگتا ہے کہ میں ایک شخص کی حیثیت سے مکمل ناکام‬

‫ہوں۔‬

This response demonstrated that the client felt like a failure and that he had been

rejected by someone. If he tried something new but it failed. He does not believe in himself.

He does not set goals.

Item no 6

I feel I am being punished. .‫مجھے لگتا ہے کہ مجھے سزا دی جا رہی ہے‬

"I must be getting punished," they said. This response demonstrated that he feels

tortured, living in a ruined world with no way out. He suffered from all of these things in

some way because of something he did wrong in the past.

Item no 8

I blame myself for everything bad that happens. ‫جو کچھ ہوتا ہے اس کے لیے میں خود کو مورد الزام‬

‫ٹھہراتا ہوں‬

This response indicated that the client reported that "I'm not good enough" or "I'm

unlovable," and that he had criticized himself. That is any problem that has arisen as a result

of my actions.

35
Item no. 10 ‫پہلے میں رو سکتا تھا لیکن اب میں چاہ کر بھی رو نہیں سکتا‬

‫۔‬

I used to be able to cry, but now I can’t cry even though I want to.

This response show that the client is facing difficult in copping and emotional control.

The depressed feeling or situations are not being properly tackled by client due to his

depressed mood.

Item no. ‫میں پہلے سے کئی گھنٹے پہلے جاگتا ہوں اور دوبارہ سو نہیں سکتا‬

I awake up several hours earlier than I used to and cannot get back to sleep.

This response indicated that the client has insomnia. He couldn't sleep for an hour. He

had been depressed for so long that he can't fall back asleep when he wakes up.

Item no. 20 ‫میں اپنے جسمانی مسائل سے اس قدر پریشان ہوں کہ اس کے عالوہ کچھ سوچ بھی نہیں سکتا۔‬

I am so worried about my physical problems that I cannot think of anything else.

Rotter’s Incomplete Sentences Blank. Rotter’s Incomplete Sentence Black is Semi

Projective Psychological test called ROTTER’S INCOMPLETE SENTENCE BLANK

(RISB) developed by Julian Rotter and Rafferty in 1950. It focuses on the use of RISB for

personality analysis of the subject. RISB is a projective psychological test use to measure the

level of adjustment or maladjustment of subject with the semi-projective scoring system. It

comes in three forms (for different age group) and comprises 40 incomplete sentences usually

only 1-2 words long, such as “I regret…..”

36
 The test comprises on deficient sentence. Its comprise of 40 thing. That is

measure the identity characteristics, negative, positive reaction and maladjustment. It is semi

projective test measure the maladjustment.

Purpose of RISB: The test explores an individual’s social familial and general attitude

toward life. It also uses to identify personal motives, need, interest, conflicts and desire both

conscious and unconscious level.

Scoring principles.

Following are the scoring principles.

Omission responses: Omission responses are designated as those for which no answer is

given or for which the thought is incomplete.

Conflict responses: “C” or conflict response is those indicating an unhealthy or

maladjusted frame of mind. These include hostility reactions, pessimism, symptom

elicitation, hopelessness and suicidal wishes. The numerical weights for the conflict

responses are C1=4 C2=5 C3=6

Positive responses: “P” or positive responses are those indicating a healthy or hopeful

frame of mind. The numerical weights for the positive responses are P1= 2, P2=1 P3=0

Neutral responses: “N” or neutral responses are those not falling clearly into either of

the above categories.

37
Response Category Corresponding Score Obtained Score

Positive Response

P3 0 2*0=0

P2 1 0*1=0

P1 2 13*2=26

Neutral Response

N 3 6*3=18

Conflict Response

C1 4 4*4=16

C2 5 8*5=40

C3 6 6*6=36

38
Cut off score: 135

Subject’s Score: 26+18+16+40+36= 136

Time: 25 minutes

Subject score is 136 and it indicates that client personality and adjusted issue. Additionally,

He doesn’t fit in with society well. He is not capable of handling societal challenges.

Interpretation

Familial Attitude responses. On a concern about family, the client’s responses were

primarily ambiguous, neutral, positive, negative, and occasionally regretful. By his specific

responses, which show that the client is emotionally connected to his family, it is possible to

observe the client's need for familial support, i.e. 25th item, "I need relationships," I

sometimes think about my family, which is item number 28. He expressed regret for his

mistake in some of his responses, but he primarily displayed a strong sense of loyalty to his

father and other members of his family.

.‫مجھے افسوس ہے کہ میرے والد کا خواب پورا نہ ہو سکا‬

‫ماں اچھی ہوتی ہے۔‬

‫میرا سب سے بڑا خوف باپ نہیں ہے‬

‫میری سب سے بڑی فکر میرے بیٹے کی پرورش ہے۔‬

‫مسئلہ یہ ہے کہ میرا خاندان میرا ساتھ نہیں دیتا۔‬

39
 ‫مجھے رشتوں کی ضرورت ہے۔‬

Social Responses. The majority of the client's responses focused on society though these

were less frequent than responses related to family. The client's responses are very typical,

and in some of them, he expressed negative attitudes toward other people, which is consistent

with how society typically perceives him. In other responses, his negative ideas about society

can also be seen.

‫لوگ برے ہیں۔‬

‫سکول میں سب اچھا تھا۔‬

‫کرکٹ کا کھیل اچھا ہے۔‬

General Responses. Client showed mostly neutral or certain responses in this area.

Although the client's perception of some general aspects is typically positive, some of his

responses have been observed to be conflicted and may also be seen as negative schemas that

have disrupted his life to a greater extent and distorted his concept.

‫یہ جگہ ٹھیک ہے۔‬

‫زیادہ تر خواتین گھر میں اچھی لگتی ہی‬

‫انسان اپنے اخالق سے پہچانا جاتا ہے۔‬

Character trait. Client showed a variety of responses regarding his individuality and

responses were mostly based on neutral or uncertain believes. The client has a negative self-

image due to certain reason which includes his childhood experience especially. He can be

40
seen as considering himself for his experience and also has responded in a way illustrating his

very bright future.

‫مجھے مصروف رہنا پسند ہے۔‬

‫بچپن میں خوف تھا۔‬

‫یہ نشہ میرے لیے تکلیف دہ ہے۔‬

‫میں اب ٹھیک ہوں۔‬

‫میرے اعصاب مضبوط ہیں‬

Conclusion.

The subject could be characterized as having not a well-balanced social and familial

attitude. The subject has a strong attachment to her parents, as seen by the responses. The

person also expressed several disturbing statements and displayed a negative temper toward

people. The subject's score is 136 out of 135 which indicates that subject doesn’t fits in

society.

Bender Gestalt Test (BGT).

Bender Gestalt test developed by Child psychiatrist Lauretta Bender (1938). The

Bender Visual Motor Gestalt test (or Bender-Gestalt test) is a psychological assessment used

to evaluate visual-motor functioning, visual-perceptual skills, neurological impairment, and

emotional disturbance in children and adult ages three and older. The Bender Gestalt is a non-

verbal, performance test widely used psychological instrument in the field of clinical

psychology (Sundberg, 1961, P.79). Bender Gestalt test differentiate into broad categories;

41
normal, neurotics, psychotics, mentally retarded, and brain injured individuals, Most recently

the test has been used with children to diagnose brain injury, to screen for school readiness, to

study mental retardation, and brain injured individual.

The standard Bender Visual Motor Gestalt consists of nine figures, each on its own

3×5 card. An examiner presents each figure to the task subject one at a time and the subject to

draw it onto a single piece of blank paper. Common features considered in evaluating the

drawings are rotation, distortion, symmetry, and preservation. The Bender Gestalt can also be

administered in a group setting.

Clinical Purpose of BGT: The Bender- Gestalt is used to evaluate visual-motor

maturity and to screen children for developmental delays. The test is also used to assess brain

damage and neurological deficits. Individual who have suffered a traumatic brain injury may

be given the Bender Gestalt as part of neuropsychological measures, or test.

Scoring.

Scoring Total Score: 13

Subject’s Score: 12

Time: 14 minutes

The client is shown rotating in Figure 8, which designates his problem in visual areas as well

as his weak motor skill, which is causing impairments, which could be a cause of substance.

Figures 6 and 7 show overlapping difficulty, indicating that the client has difficulties with

motor skills as well as difficulty interpreting stimuli and distortion in his perception. Figures
42
2, 3, 4, and 5 demonstrate the client's immaturity in accurately and precisely perceiving life

events. Fragmentation errors were also discovered in 2, 4, and 5. The client is struggling with

visual maturity and visual motor integration.

Retrogression error found in 1, 2 and 5 which indicate that client gas inability

evaluate visual maturity, visual motor integration skills, style of responding, reaction to

frustration, ability to correct. Figures 2 and 3 show the client's perseveration effect, which

highlights his conservative personality because he cannot perceive things as they are. Client's

collision error in figure 2 depicts his aggression and may be a valid indicator of his anxiety.

Impotence errors found in A, 3, 4, and 7 indicate that the client is unable to express himself

behaviorally and verbally. Figures A and 4 show the difficulty of closure. His drawings

depict motor skill deficiencies, anxiety, and aggression. Client demonstrated motor

coordination in figures A, 3, 6, and 7. The client drew the figures with weak and disturbed

lines.

Figure 3 depicts the angulations effect, which represents the client's excessively

weak motor skill, and he may have difficulty even perceiving normal difficulty levels in

perceiving stimuli. Figures A and 5 depict cohesion. The figures drawn are much larger than

the given figures, demonstrating his level of aggression. The client received a score of 12,

indicating very strong evidence of brain impairment.

Case Formulation.

The client was a 27-year-old early adult from Rawalpindi. He's been married for

two years and has one son. He was in an arranged marriage and had a tense relationship with

his wife. He had a troubled childhood. He was always bothered by parental relationship

issues. His family was always moving from one city to another, so he never made true

43
friends. Because of his history of difficult and problematic education, he dropped out of

school after the tenth grade. The client was uninterested in good company, which led to drug

abuse.

He claimed to have been more sensitive as a child than his siblings and or

sometimes, as a result of parental conflicts that led to his exploitations and a general turmoil,

he displayed aggression. When the girl he loved left him, he fell into a deep depression. At

the age of 18, the client reported a history of drug treatment at Nejjat Trust Rawalpindi. He

claimed that his drug rehab was ineffective and that his relapses began once more after the

death of his father and the cruel behavior of his wife and mother and he claimed credit for his

dad's death. Because of him and his friend, the client has had a problem ever since, which he

attributes to the fact that after using cigarettes for the first time, his curiosity gradually

increased and he later started using marijuana and opioids.

Currently, he is at Nijjat Trust Rawalpindi. According to the client's complaint, he

experienced mood swings, a headache, and tingling in his eyes and nose as a result of his

withdrawal symptoms. The Bender Gestalt Test, the Rotter's Incomplete Sentence Blank, and

the Beck Depression Inventory were used for formal evaluation.

Supporting Theories

Social Learning Theory

Social learning theory, proposed by Albert Bandura, emphasizes the importance of

observing, modeling, and imitating the behaviors, attitudes, and emotional reactions of others

and is influenced by factors such as attention, motivation, attitudes, and emotions. The theory

44
accounts for the interaction of environmental and cognitive elements that affect how people

learn.

The theory suggests that learning occurs because people observe the consequences

of other people's behaviors. Bandura's theory moves beyond behavioral theories, which

suggest that all behaviors are learned through conditioning, and cognitive theories, which

consider psychological influences such as attention and memory.

According to Bandura, people observe behavior either directly through social

interactions with others or indirectly by observing behaviors through media. Applied to

addictions, the social learning model suggests that drug and alcohol use are learned

behaviors and that such behaviors persist because of differential reinforcement from other

individuals, from the environment, from thoughts and feelings, and from the direct

consequences of drug.

Social learning theorists would suggest that people fall into alcohol addiction due to

modeling. If an individual grows up in an environment where others appear to be rewarded

for drinking alcohol, there will be a strong motivation to copy the behavior.

It is reasonable to assume that the client imitated or observed the behavior of a drug-

using friend. Client grew up in an environment where he received positive reinforcement via

drugs.

Anxiety, according to Sigmund Freud.

According to Sigmund Freud, Anxiety is a feeling of a dread that results from

repressed feelings, memories, desires, and experience that emerge to the surface of

awareness. It can be considered as a state of tension that motivates us to do something.

45
 Anxiety is a feeling of impending danger. Sigmund Freud (1856-1939) considered

three types. Objective anxiety results from a real threat in the physical world to one's well-

being, as when a ferocious-looking dog appears from around the corner. The other two types

are derived from objective anxiety. Neurotic anxiety results from the ego feeling

overwhelmed by the id, which threatens to express its irrationality in thoughts and behavior.

Moral anxiety is based on a feeling that one's internalized values are about to be

compromised.

The client's relatively anxious behavior in conversation and tests, such as

Rotter’s Incomplete Sentence Blank test, has all been observed. The client appears to be in a

relatively anxious state, which is assumed to be related to his previous experience as well as

his desire or needs, which he is afraid or uncomfortable to express.

Ego Defense Mechanisms.

Ego Defense mechanisms are methods people use to cope with feelings of stress or

anxiety. It occurs when you refuse to accept reality or facts for most people, defense

mechanisms are unconscious behaviors. Freud believed people unconsciously used defense

mechanisms to help protect themselves from difficult or uncomfortable thoughts, feelings, or

situations.

Defense mechanisms have two characteristic in common;

1. They either deny or distort reality

2. They operate on an unconscious level.

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Defenses Specification Use in behavior Justification

Attributing to others This is the mechanism It is justify that Client

one’s own of self-deception. stated that he took drugs

Projection
unacceptable desires Lustful, aggression, or because of his friends, but

and impulse. other impulses are seen that after a long time, when

as being possessed by he was gone, he also took

“those people out there, drugs. Client projected his

but not in himself. own unacceptable behavior

and actions as possessed

by his friend, rather than

by himself. The client was

essentially saying that

every time I took a drug

because of him, it was not

my fault.

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Rationaliz Manufacturing Rationalization help It is justified that the client

“good” reasons to justify specific describes his situation as

ation
explain away a buried behaviors, apparent hopeless and sad about his

ego. logical reasons are current situation, but he is

given to justify also reinterpreting his

behavior that is behavior to make it more

motivated by acceptable, and he is

unconscious instinctual saying that when I leave

impulses. this place, I will become a

big man.

Psychodynamic Theory.

Psychodynamics originated with Sigmund Freud in the late 19th

century. According to Freud (1915), the unconscious mind is the primary source of human

behavior. Our feelings, motives, and decisions are actually powerfully influenced by our past

experiences, and stored in the unconscious.

Psychodynamic theory states that events in our childhood have a great influence on

our adult lives, shaping our personality. Events that occur in childhood can remain in the

unconscious, and cause problems as adults. Personality is shaped as the drives are modified

by different conflicts at different times in childhood (during psychosexual development).

It is reasonable to assume that the client's childhood experience was so tragic that he

went through the entire trauma and crises. The client stated from the start that he grew up in a

very disputed and disturbed family system, which affected him in adulthood. He observed his

parents' marital problems, and he lived through all of his childhood traumas and conflicts,

48
which influenced his adult life. It is possible that he had a bad marriage because of his

parent's relationship problems, and he learned about these marriage problems from their

parents, and now he has a bad relationship with his wife.

Adlerian Theory

Alfred Adler was an Austrian physician and psychiatrist who are best-known for

forming the school of thought known as individual psychology. He is also remembered for

his concepts of the inferiority feeling and inferiority complex, which he believed played a

major part in the formation of personality.

According to Adler’s, Order of birth is a major social influence in childhood, one

from which we create our style of life. Even though siblings have the same parents and live in

the same house, they do not have identical social environment. Being older or younger than

one’s siblings and being exposed to differing parental attitudes create different childhood

conditions that help determine personality.

First-Born Child

First-born children have inherent advantages due to their parents recognizing them as

“the larger, the stronger, and the older. “This gives first-born children the traits of “a guardian

of law and order.” These children have a high amount of personal power, and they value the

concept of power with reverence.

Second-Born

Adler's theory was that second born children, due to their place in the family birth

order, generally feel overshadowed. Since the first child is more likely to receive more

responsibilities, and the youngest child is more likely to be pampered, this leaves the middle

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and second child with no clear role or status within the family. Second born of bigger

families often isn’t as competitive as single middle children, since their parents' attention is

spread thinner for bigger family dynamics.

For example, the older sibling excels in sports, the second born may feel that he or she

can never surpass the first-born and may give up trying.

Youngest Child

Youngest sibling in a family is way more likely to take risks in their developing careers

and thus end up far more successful and way more likely to be a millionaire.

Only Child

Only children never lose the position of primacy and power they hold in the family;

they remain the focus and center of attention. Spending more time in the company of adults

than a child with siblings, only children often mature early and manifest adult behaviors and

attitudes.

It is reasonable to assume that the client is of second birth. Everyone admired his

elder brother, so he always thought he could never surpass him, so he tried to give up.

Cognitive theories of Major Depression

Cognitive behavioral theorists suggest that depression results from maladaptive, faulty,

or irrational cognitions taking the form of distorted thoughts and judgments. Depressive

cognitions can be learned socially (observationally) as is the case when children in a

dysfunctional family watch their parents fail to successfully cope with stressful experiences

or traumatic events.

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 Dr. Aaron Beck (1967) postulated that depression is associated with a negative triad;

negative views of the self, the world, and the future. The “world part” of the depressive triad

refers to the person’s own corner of the world the situations he or she faces. According to this

model, in childhood, people with depression acquired negative schema through experiences

such as loss of a parent, the social rejection of peers, or the depressive attitude of a parent.

Schemas are different from conscious thoughts. The negative schema is activated whenever

the person encounters situations similar to those that originally caused schema to form. Once

activated negative schemas are believed to cause cognitive biases or tendencies to process

information in certain negative ways (Kendall & Ingram, 1989). Beck suggested that people

with depression might be overly attentive to negative feedback about themselves. They

might have overly persistent memories of that negative feedback.

The client appears to have developed negative schema on which he cognitively drills.

His overall life experience in the present and past may be influenced by his negative schemas.

Client experienced sadness, loneliness, and depression as a child, as well as in the present and

possibly in the future. His perception of the world around him, his history, and some time his

future expectations appears to be so negatively interpreted that the client may be unable to

cope.

Tentative Diagnose.

According to DSM-V, the client’s current condition and symptoms are diagnosed with

(F12.10) cannabis withdrawal.

The client is experiencing issues in the social and environmental spheres. The client's

family caused him problems when he was a child. He lost his father and received insufficient

51
emotional support from his surroundings. The client's history of academic issues included

significant problems with educational issues. He had health problems as well.

A Beck Depression Inventory was completed by me (BDI). On the BDI scale, he

received a score of 43, which indicates extreme depression, although since I only have

information from one test, I am unable to make a diagnosis of depression. It might be a result

of his mood effect or a situational factor that pushes him toward depression. I think that

additional tests should be performed to properly diagnose a patient with depression.

Therapeutic Recommendation

The term "therapeutic recommendation" refers to the suggestibility of standardized

treatment plans for any individual with specific problems or issues that are affecting or

disturbing his or her way of life, based on scientific evidence and research. Family therapy,

CBT, REBT, in my opinion, are necessary for its treatment.

Rational Emotive Behavioral Therapy. Rational emotive behavior therapy (REBT)

is a type of therapy introduced by Albert Ellis in the 1950s. It’s an approach that helps you

identify irrational beliefs and negative thought patterns that may lead to emotional or

behavioral issues. The basic assumption of REBT is that people contribute to their own

psychological problems, as well as to specific symptoms, by the way they interpret events

and situations (Ellis, 1994, 1999, 2001a, 2001b, 2002, 2008, Ellis & Dryden, 1997); Wolfe,

2007).REBT attempt to help them accept themselves as creatures who will continues to make

mistake yet at the same time learn to live more at peace with themselves (Corey, 2008)

REBT can be particularly helpful for people living with a variety of issues,

including: Depression, anxiety, addictive behaviors, phobias overwhelming feelings of anger,

52
guilt, or rage, procrastination, disordered eating habits, aggression, and sleep problems.

REBT is an action-oriented approach that’s focused on helping people deal with irrational

beliefs and learn how to manage their emotions, thoughts, and behaviors in a healthier, more

realistic way. The goal of REBT is to help people recognize and alter those beliefs

and negative thinking patterns in order to overcome psychological problems and mental

distress.

Cognitive Behavioral Therapy. Cognitive behavioral therapy is defined as

"psychotherapy that combines cognitive therapy with behavior therapy by identifying faulty

or maladaptive patterns of thinking, emotional response, or behavior and substituting them

with desirable patterns of thinking, emotional response, or behavior.

Cognitive behavioral therapy focuses on changing the automatic negative thoughts

that can contribute to and worsen our emotional difficulties, depression, and anxiety. Through

CBT, faulty thoughts are identified, challenged, and replaced with more objective, realistic

thoughts.

CBT is used to treat a wide range of conditions, including: Addiction, Anger issues,

Anxiety, Bipolar disorder, Depression, Eating disorders, Panic attacks, Personality disorders,

Phobias. The goal of cognitive behavioral therapy is to teach people that while they cannot

control every aspect of the world around them, they can take control of how they interpret

and deal with things in their environment.

Adlerian Counseling Therapy. Adlerian psychotherapy is both humanistic and goal

oriented. It emphasizes the individual's strivings for success, connectedness with others, and

contributions to society as being hallmarks of mental health. Birth order is considered

53
important in understanding a person's current personality, yet the therapy is future-minded,

rather than retrospective.

Adlerian counseling is structured around four central objectives that correspond to the four

phases of the therapeutic process (Dreikurs, 1967). These phases are as follow;

1. Establish the proper therapeutic relationship.

2. Explore the psychological dynamics operating in the client (an assessment).

3. Encourage the development of self-understanding (insight into purpose).

4. Help the client make new choices (Corey, 2008)

Family Therapy. Family therapy is a type of treatment designed to help with issues that

specifically affect families' mental health and functioning. It can help individual family

members build stronger relationships, improve communication, and manage conflicts within

the family system. By improving how family members interact and relate to one another,

family therapy can foster change in close relationships..

 Psychoeducation. This type of treatment is centered on helping family members

better understand mental health conditions. By knowing more about medications,

treatment options, and self-help approaches, family members can function as a

cohesive support system.

Freudian Psychoanalytical therapy. Psychoanalytic therapy is a form of talk

therapy based on Sigmund Freud's theories of psychoanalysis. The approach explores how

the unconscious mind influences your thoughts, feelings, and behaviors. Specifically, it

examines how your experiences (often from childhood) may be contributing to your current

experience and actions.

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 Therapeutic methods are used to bring unconscious material. Then childhood

experiences are discussed, interpreted and analyzed. There is a deeper probing into the past to

develop the level of self-understanding that is assumed to be necessary for a change in

character. Psychoanalytic therapy may be used to treat a number of different psychological

conditions, including: Anxiety, Depression, Emotion struggles or trauma, Identity problems,

Self-esteem issues, Self-assertion, Psychosomatic disorders, Relationship issues, Self-

destructive behavior.

The psychoanalytic approach helps people explore their pasts and understand how it

affects their present psychological difficulties. It can help patients shed the bonds of past

experience to live more fully in the present.

Couple Therapy. Couples therapy is a form of psychotherapy that can help you and your

partner improve your relationship. If you are having relationship difficulties, you can seek

couples therapy to help rebuild your relationship. “Couples therapy can address a wide range

of relationship issues, including recurring conflicts, feelings of disconnection, an affair,

issues related to sex, or difficulties due to external stressors,

Psychodynamic couple’s therapy: Psychodynamic therapy explores the underlying

hopes and fears that motivate you and your partner, to help you understand each other better.

Drug Therapy.

Agonist Approach. One strategy to treat drug dependence is long-term treatment with the

same agonist drug or with a cross-tolerance drug to suppress withdrawal craving. This

approach is successfully used in the treatment of tobacco (nicotine) dependence (nicotine

itself) and opiate dependence (methadone, buprenorphine). It is being studies for treatment of

55
cannabis medication for appetite stimulation and suppression of nausea and vomiting due to

chemotherapy.

Use of Oral Synthetic THC in outpatient was reported in a study that showed the

potential benefit, as well as questions that arise from the use of this medication in cannabis-

abusing populations. Controlled clinical trials of oral THC are currently underway.

56
 References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental

Disorders (5TH Ed). Washington, DC: Author

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental

Disorders (4TH Ed., text rev.). Washington, DC: Author

King, A.M., Johnson, S.L. Davison G.C., & Neale, J.M., (2012). Abnormal Psychology.

Hoboken, NJ (12th Ed). New York, NY: John Wiley & Sons.

King, A.M., Johnson, S.L. Davison G.C., & Neale, J.M., (2009). Abnormal Psychology.

Hoboken, NJ (8th Ed). New York, NY: John Wiley & Sons.

Groth and Marnat, (1997). Handbook of Psychological Assessment (3rd edition). New York:

John Wiley and Sons.

G. Corey (2008). Theory and practice of Counseling and Psychotherapy (8th ed.), California

State University, Fullerton: American Board of Professional Psychology.

Kaplan, Robert M., Saccuzzo, & Dennis P. (2009). Psychological Testing: Principles,

Applications, and Issues: United States of America.

Natioanl Collaborative on Workforce and Disability for Youth. (2002). Transition tools of

Assessment, Boston and Western massachuetts:Author.

John M. Grohol, Psy.D. (2004). Types of Therapies, Theoretical Orientations and Practices

of Therapists: Retrieved from http://psychccentral.com/therapy.htm

Beck. A.T. Epstein, N., Brown, G., & Steer, R.A. (1972). Depression: Causes and Treatment.

University of Pennsylvania Press. ISBN 0-8122-1032-8. Philadelphia

Crocker, J., Luhtanen, R., Blaine, B., & Broadnax, S. (1994). Collective self esteem and

Psychological well-being among White, Black, and Asian College students.

Personality &Social Psychology Bulletin: 20(5), 503-513.

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Annexure (Drug Client’s Response Sheet)

58