Case History Taking

Socio-Demographic Data:
Name– Mr. N.A
Age and Gender- 27 year-old male
Education- Unlettered
Marital Status- Unmarried
Occupation- None
Socioeconomic Status- Lower Middle class
Informant- Self

Complaints and their Duration:

• Sleep Attacks: Acute onset and episodic course
• Irritability: Acute onset and continuous course.
• Lability in Mood: Acute onset and continuous course.
• Guilty: Gradual Onset and episodic course.
• Aggressive Behaviour: Acute Onset.

History of Present Illness:

The client reported that the sleep attacks first occurred one month ago and he is unable to resist them.
He stated that he had requested to see the psychiatrist and irrespective of the decrease in dosage, he
is unable to resist the sleep attacks. The client stated that he experiences irritation occasionally and
has experienced this over the past one month. He said that he attempts to control his irritation by
lying down but fails to control the feelings. Furthermore, he stated that his mood ranges in extremes.
He experiences intense mood swings that last for a couple of minutes and fade away. However, he
said that the mood swings occur repetitively. Also, the client reported that he felt guilty of his actions
and was constantly reminded of the harm he has done to himself and his family. He mentioned that
his feelings of guilt had intensified over the past week. Lastly, the client stated that he had aggressive
tendencies and aggressive behavior that he had experienced lately.

Past History:
The client had no major medical pattern reported. However, the client reported multiple substance
abuse including cannabis and benzodiazepines. He stated that he started consuming cannabis in 2012
and had been admitted to the facility of CARE for the fifth time now. His first admission to the
facility was in 2012 wherein he stayed here for a period of 3 months. The second admission was in
the year 2013 lasting for 3 months. Similarly, he was admitted to the facility in 2016 and 2017 for a
period of 3 months respectively. He stated that he consumed cannabis as he had difficulty in falling
asleep. The client reported that he was caught by the police having cannabis in possession.
Furthermore, he had been involved in various physically abusive fights with strangers that resulted in
the client being jailed four times in the past. The client reported that he did not experience any
withdrawal symptoms over the past few years. He stated that environmental factors such as the
places where he would consume cannabis and peers were the major causes for relapse. He was
unable to resist the craving of the drugs when he was with his peers.
Family History:

The client reported that he is very close to his family which includes his father, mother and a
younger sister. He stayed with his family and was not majorly involved in the decisions made. His
sister is married and his mother takes care of the house. He reported that there was no family history
of substance abuse or medical illness. He stated that his father was the leader of the family and the
client would help him in the business occasionally.

Personal History:
1. Birth and Early Development: FT-NVD with immediate birth cry and achieved all
developmental milestones within normal limits.
2. Behaviour during Childhood: Normal childhood with love and support from the family members.
3. Physical Illness during Childhood: None reported.
4. Educational History: The client reported normal schooling, however mentioned a desire to have
completed his twelfth standard.
5. Occupational History: Tailor
6. Menstrual History: Not Applicable
7. Sexual History: None Reported.
8. Marital History: None.
9. Use and abuse of alcohol, tobacco and drugs: Use of Cannabis and benzodiazepines reported.

Pre-morbid Personality:
The client is a follower and is emotionally cold. He has a negative attitude towards himself and the
others around him. He was unsatisfied with his work and wasn’t concerned about his health. Severe
moral and religious attitudes are reflected in the upbringing of the client and his faith in god. He
experiences irritable mood swings and is unable to express his feelings. The client’s leisure activities
include listening to music and watching movies. He stated that he did not see any dreams at night.
However, he spent almost an hour day dreaming. He stated that he experienced difficulty in sleeping
over the past few weeks.

Mental Status Examination (MSE):

1. General Behavior: Normal gait, adequate eye contact and normal behavioral functioning.
2. Psychomotor Activity: Below Average level of activity.
3. Talk: Relevant, Spontaneous speech with normal tone, pitch and rate.
4. Thought: Normal stream and form, no possession/ abnormal content.
5. Mood: Euthymic as observed; occasional irritability and lability of mood as reported.
6. Perception: No hallucinations, delusions.
7. Cognitive Functions:
Attention and concentration: Normal.
Orientation: Well oriented.
Memory: Immediate, recent and remote memory reported to be normal.
General Information: Adequate knowledge of general information.
Intelligence: Average.
Abstractibility: Average.
Judgement: Sound judgment about personal, social and test situations.
8. Insight: Level V, Fully present.

Case Formulation:
Thus, the client has psychoactive substance use disorder. No other past/family history of
physical/psychological disorders present. This reflects a diagnosis of F12. F1x.21 - Mental and
Behavioural disorders due to use of Cannabinoids as per the ICD 10. Pharmacological treatment
along with individual psychotherapy is recommended. The prognosis seems good however, peer
influence needs to be attended to immediately.

Co-morbidity:

– F13.F1x.00 – Mental and Behavioural disorders due to use of sedatives and hypnotics –
Uncomplicated.