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CLINICAL CASE STUDIES

Internship Reports

By

Maham Mahmood

Roll # 15384

BS Applied Psychology

Department of Applied Psychology

Riphah International University, Faisalabad

Session: 2019-2023
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Place of Internship

Mujahid Hospital, Faisalabad

Punjab Institute of Mental Health, Lahore

Duration of Internship

29th October to 15th February

16th February

Supervisor at Internship

Sir Saleem (HOD)

Maam Fareeha Akbar

Supervisor at Department of Psychology

Maam Sidra Ilyas

Signature
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TABLE OF CONTENTS

Serial no Contents Page no

4
1 Clinical Case Study No 1

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2 Clinical Case Study No 2

Appendices
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PSYCHODIAGNOSTIC REPORT

Client’s Name: Mr. ABC

Father’s Name: Mr. XYZ
Date of Birth: June 21st, 1962
Age: 36 Year
Sex: Male
Qualification: Matriculation
Marital status: Divorced
Religion: Islam
Socio-economic Status: Upper Middle Class
Father Occupation: Petroleum Engineer
Family System: Nuclear
Parents: Mother Alive & Father Died
Siblings: 2 brothers, 3 sisters
Residence: Lahore
Referral: Family
Date of Assessment: 16th February, 2023.
Examiner: Sir Saleem Abbas
Case: 01

Identifying Information

ABC is a 36 years old single male. He is 3rd born among 2 brothers and 3 sisters. His
qualification is Matric and he is unemployed. He have 1 Son. His father passed away. His
mother’s qualification is under matriculation and she is a house wife. He belongs to an Urdu
speaking, Muslim family with upper middle class socio economic status. He is divorced. He lives
in a Nuclear family set up and resides at Johar town Lahore.

Referral Source and Presenting Complaints

ABC referred by his family to to Punjab Institute Of Mental Health (PIMH) for the purpose of
psychological assessment and psychotherapy. His presenting complaints include; anxiety , guilt,
sleep deprive issues and want to go back to work and home quickly.

Interview Information

ABC reported that his problems started since his age was 33 years. He further reported till age of
32 years old he was fine and all things in his life was going good, he was working as manager in
oil and gas factory and was married. His personal and professional life got affected due to drugs.
Regarding his friendship history client reported that he has limited circle of friendship.
Regarding his family history client reported his family relationship is good. Regarding his work
history, client reported that he worked as a floor manager in Oil & Gas factory. Now he wanted
to work again.
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Method of Taking Drugs:

He did drugs of Cannabis, Marijuana and Hashish. When he was 33 years old he started doing
drugs. In one day he use to take 1.5gram or 2 gram of Marijuana or Cannabis. He used drugs for
2 years According to him when his parents found out about his addiction than they took him to
Punjab Institute Of Mental Health (PIMH) for his drug therapy. He has recently completed his 3
years of Substance Abuse Treatment. His prior medication consist of Kempro 31mg and
Dapakan 4 Tablets which he has used for 1.5 Years regularly and is now claiming he’s recovered
and is ready to go home.

The client daily routine include waking up, sometime offer prayer 1or 2, then he does his
breakfast he takes classes which is provided by the institute, he plays bedminton then he does his
evening meal, then rest, then tea time goes to his room and then he does his dinner around 8pm,
then take medicine, and then sleep. The food is provided by the institute. The client reported that
he used to play snooker before his drug addiction and now he likes to play badminton. He also
likes to participate in sports competition which held in the institute of PIMH.

Goals of Life:

The client reported that he have goals for his life. He wants to get married and work again. The
client reported that his sleeping pattern are normal and he often dreams about his parents and
home. He miss his old life and wanted to home. His degree of insight was quiet good and he was
intellectual also.

Tests Administered

 Human Figure Drawing Test…………………………(HFD)

 Bender Gestalt Test………………………………….(BGT)

Behavior During Assessment Sessions

During assessment sessions Mr. Khurram was positive towards assessment. He came on time for
sessions and took interest in assessment. He tried to perform on all administered tests adequately.
Overall his behavior was very cooperative throughout assessment sessions. His posture was
normal his way of talking was slow and has good manners. He was using Urdu language and was
open, relaxed and cooperative throughout the interview. Client degree of insight was good was
quite intellectual.
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Psychological Evaluation

Human Figure Drawing Test (HDF)

Projective analysis reveals that client’s has Anxiety issues .He has ambitions for accomplishment
and drives. He’s self-conscious and has symbols of virility with regression. He feels guilt and

socially dependent. He has developed self indulgence and voyeuristic tendencies . Projective
analysis reveals that client’s self-image is negative.

Bender Gestalt Test (BGT)

On neuro psychological Screening Test (BGT) client’s score falls within ‘Average’ range, which
indicates that client’s visual motor perceptual functioning is intact. Further, emotional indicators
shows that client has aggression, impulsivity and anxiousness.

Tentative Diagnosis

292.0( F12.288) Cannabis With Drawl Disorder.

Recommendations

 Cognitive behavioral therapy (CBT) for substance use disorders has demonstrated
efficacy as both a monotherapy and as part of combination treatment strategies.

 Cognitive Behavior Therapy can be recommended as it would allow the client to work
those thinking patterns which are causing the client’s issues through the use various
techniques including ABC model which will develop insight in the client as to how his
problem has occurred and identify and address the source of the negative thinking that
cause depression.

 It can be recommended that the client’s self-esteem be focused on and improved by way
of positive reinforcement and motivation.

Supervisor Examiner

Mam Sidra Ilyas Saleem Abbas PHD

Mam Fareeha Akbar Assistant Professor

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PSYCHODIAGNOSTIC REPORT

Client’s Name: Mr. ABC

Father’s Name: Mr. XYZ
Date of Birth: Unremembered
Age: 65 Year
Sex: Male
Qualification: Matriculation
Marital status: Divorced
Religion: Islam
Socio-economic Status: Middle Class
Father Occupation: Leather shop work
Family System: Nuclear
Parents: Mother Alive & Father Died
Siblings: 1 sister
Residence: Lahore
Referral: Family
Date of Assessment: 16th February, 2023.
Examiner: Saleem Abbas
Case: 02

Identifying Information

The client is a 65 years old single male. He is 1st born and has 1 younger sister. His qualification
is Matriculation and he is unemployed. His father was illiterate and his occupation was leather
shop worker. His mother’s is also illiterate and she is a house wife. He is divorced. He have 1
son. He belongs to a Punjabi speaking, Muslim family with middle socio economic status. He
lives in a Nuclear family set up and resides in Lahore.
Referral Source and Presenting Complaints

ABC referred by his family to Punjab Institute Of Mental Health (PIMH) for the purpose of
psychological assessment and psychotherapy. His presenting complaints include; tension,
anxiety, heart issue, some time visual and auditory illusions, sleep deprived and appetite
starvation issues and he want to become Saint (Wali) and he wants to go home.

Interview Information

ABC reported that his problems started since his 30s. He further reported till age of 29 years old
he was fine and all things in his life was going good, he was working in his leather shop and was
salesman and also was married. But after that he fall in love with a girl and she left him after that
he was very depressed and he started doing drugs.
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Method of Taking Drugs:

He was using opium for 5 to 8 years which he named as “Kushi ki Goli”. He use to take opium
in tablet from almost 300 tablets of opium in a day.

Affects of Opium:

He further added that he was feeling like someone has applied spirit medicine on his wound. He
felt nauseous due to food. He lost his consciousness for 3 days and he has also received electrical
shocks when he was first arrived in PIMH. He use to hear voices. His nose used to bleed and he
also experienced severe headaches. His sister has sent him into PIMH because he use to fight
with his sister.

Prior Medications:

His prior treatment consist of Substance Abuse Treatment. His medications include Stalin and
Kemadrin 100mg.

Personal History:

Regarding his family history client reported that he has good relationship with family. But he
thinks that those relationship has ruined his life. He behave aggressively with his family due to
his aggression they have sent him in PIMH. According to him his whole family is not caring and
supportive for him except his mother, she is caring and loved him. Regarding his friendship
history client reported that he has limited circle of friendship.

The client daily routine include waking up he do not offer prayer and then he does his breakfast,
then he sits with his friends and do activities in the institute then he does his lunch, then rest,
then tea time, comes out of room, then he does his dinner, then take medicine, and then sleep.
The food is provided by the institute. He takes sleeping medications. He also experience
compulsions and hallucinations. He has attempted suicide one time. He often get upset. He is
afraid from influential people like police and politicians. He further added that his uncle also
uses to take drugs.

Goals of Life:

Client reported that he want to go home and live with his son and mother he often miss his
mother and son. He believes that his son will take care of him. He wants to marry also but he
believes in love marriage and thinks that only love marriages are successful.
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Tests Administered

 Bender Gestalt Test………………………………….(BG)

 Human Figure Drawing Test…………………………(HFD)
 Thematic Apperception Test………………………….(TAT)

Behavior during Assessment Sessions

During assessment sessions Mr. Aslam was positive towards assessment. He came on time for
sessions and took interest in assessment. He tried to perform on all administered tests adequately.
His posture was normal his way of talking was slow and has good manners. He was using Urdu
language and was open, relaxed and cooperative throughout the interview. Overall his behavior
was very cooperative throughout assessment sessions. Client degree of insight was good but he
was not intellectual and has memory issues.

Psychological Evaluation

Human Figure Drawing Test (HDF)

Projective analysis reveals that client’s self-image is negative. He has anxiety issues over sexual
needs possibly contour. He has castration fears and wishes due to which he has developed
contemptuous attitude and immaturity. He has aggressive tendencies and poor judgment. He
viewed opposite sex stronger and his conception of self is dependent, helpless and insignificant.
Due to which he experience anxiety, uncertainty, tension and insecurity. Over all depressive
personality.

Bender Gestalt Test (BGT)

On neuro psychological Screening Test (BGT) client’s score falls within ‘Below Average’ range,
which indicates that client’s visual motor perceptual functioning is intact. Further, emotional
indicators shows that client has aggression, impulsivity and anxiousness.

Thematic Apperception Test (TAT)

Projective analysis reveals that client has need of affiliation and succorance he want to be close
to another person and win their attention and friendship he wants to be loved, nursed, helped,
forgiven and consoled by someone. He developed conflicts like intimacy vs. isolation, trust vs.
mistrust and autonomy vs. shame. He has poor control on his impulses. Projective analysis
reveals that client has serious level of maladjustment that reflects depression and inadequate
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perceptual habit. Moreover, he is defensive due to his insecurities. He has difficulties to use his
inner resources.

Tentative Diagnosis

292.84( F11.14) Opium Induced Depressive Disorder.

Recommendations

 CBT is a flexible, adaptable treatment tool that has been used successfully in addiction
programmes all around the world. It can be used either in individual or group therapy
settings, and has been found to be highly effective in the treatment of addictions and
addictive behaviors.

 Cognitive Behavior Therapy can be recommended as it would allow the client to work
those thinking patterns which are causing the client’s issues through the use various
techniques including ABC model which will develop insight in the client as to how his
problem has occurred and identify and address the source of the negative thinking that
cause depression.

 It can be recommended that the client’s self-esteem be focused on and improved by way
of positive reinforcement and motivation.

 Assertive training recommended that the client’s communication skills be worked on and
improved in order to allow the client to be to express his emotions clearly and enable him
to have healthy relationship with others including family and friends.

Supervisor Examiner

Mam Sidra Ilyas Saleem Abbas PHD

PHD

Mam Fareeha Akbar Assistant Professor

Professor