Professional Documents
Culture Documents
CASE
CASE
SUBMITTED TO
SUBMITTED BY
Laiba Hameed
1469-FSS/BSPSY/F20
BS 8th B
Department of Psychology
A man of age 37 years, having an average physique came to a hospital named Safe Care
Trust International with crisis intervention for the treatment of substance use. After MSE, it was
observed that the client is well-groomed, neat and clean, conventional uniform, coordinated
psychomotor behavior, and consistent eye contact. Symptoms of auditory and visual hallucinations
were present along with paranoid and aggressive behavior. The choice of drug was Amphetamine
& Opioid. The client had no insight into his illness and was at the pre-contemplation stage of
motivation.
Identifying Information
Name: M.I.
Age: 37 years
Gender: Male
Education: Primary
Father: Died
Mother: Died
Religion: Islam
Referral: Upon seeing his bad condition he was brought to the hospital by his wife and brother.
Presenting Complaints:
عجیب عجیب آوازیں ی
غلط غلط تصویریں دکھائ ی،آت ںہی
دیت ںہی۔
Initial Observation:
The client was of average height and overall physique with quite a low mood. He had a
dependency on opioids and amphetamines. He was not willing to be treated and had no motivation.
He was alert and well-groomed. He maintained eye contact and answered every question logically.
He was defensive when asked for the reasons for his addiction.
According to the client, he started smoking at the age of 12 years just to have fun and
pleasure. He had some friends who were addicted to smoking and because of them (peer pressure)
he started smoking too. Gradually he became involved in the habit of other drugs such as cannabis.
The client reported that his brother was also addicted to drugs and alcohol. He was and still is
dependent on his other brother for financial means. His average daily expense on drugs is Rs.
1000/-. The client married at the age of 26 years and also started working at the shop but became
more addicted to the drugs. He is not motivated to leave the drugs because it gives him pleasure.
The client has paranoid tendencies and other psychiatric symptoms are also present such as visual
Personal History:
Birth History:
The client was born through a normal birth procedure. The client achieved all his
developmental milestones at the appropriate time. The client had no significant report of head
Educational History:
The client did his primary schooling at a local school in his town. Then he was unable to
continue his studies due to the financial crisis in his household. He was good in behavior with
everyone till he was in school. He always respected everyone who was senior to him and also had
Occupational History:
The client started working 5 years ago as a shopkeeper and too left the job because he was
not attentive and had concentration issues as his health was getting worse. Now he is dependent
Sexual History:
The client had no issues due to his sexual desires and had good control over his impulses.
Before developing the illness, the client showed determination and resilience due to strong
family values. Growing up with limited opportunities, he might have had ambitions but kept to
himself, trying new things like experimenting with drugs out of curiosity and peer pressure, his
psychosis, later on, was likely influenced by a mix of these traits, life challenges, and how
amphetamines affect the brain, showing how complex mental health can be in such situations.
Family history:
The client’s father and mother died at an early age so he lived with his siblings. He has 7
brothers and 3 sisters. He is a 9th born among them so there is a age gap between him and his
siblings so he has barely any communication with his siblings. He is not satisfied with the
environment of his home because according to him the people at home get into fights occasionally.
He married at the age of 26 years. It was an arranged marriage and now he has three sons. He
reported that his wife used to insist him to not take drugs, which shows that he is responsive to his
Family history of substance abuse was reported. He told that his brother is into taking drugs
and he is alcoholic.
Psychological Assessment:
To assess client’s problem two types of assessment were carried out that were as follows:
Informal assessment:
• Clinical interview
Formal assessment:
• HTP
• RISB
Clinical Interview:
It's a professional face-to-face encounter with a clinician; who asks questions about the
client’s problems, along with the client’s reactions and all responses. The clinician collects all
types of detailed information of the client’s problem, lifestyle, feelings, emotions, relationships
and other personal history. A clinical interview was conducted with the client to get detailed
information about his personal history; finding the cause and starting of the problem, his family
history his relationship with his family and other relatives, his sexual history, educational
information, occupational, and social history. The client had no insight about the problem and had
MSE
MSE is done with patient at first presentation to the clinical psychologist to assess about
his/ verbal and nonverbal symptoms of illness.it provides basis for psychiatric diagnosis and
clinical assessment. The client’s appearance was alerted, well-groomed and neat in general. He
showed a coordinated psychomotor behavior and showed consistency. He maintained the eye
contact with the examiner. He was defensive about his drug using habit but was cooperative with
the clinician in every question he asks. He felt drowsiness and sleepy at times. He was a well-
oriented person but his attention was scattered and had difficulty in concentrating. He had an
average cognitive and spatial ability and was answering the question logically. He had the
symptoms of psychosis such as auditory and visual hallucinations, paranoid tendencies and
showing aggression from time to time. He had a poor control about his impulses and couldn’t
The client has scored 8 on BAI, which shows that he has a minimal level of anxiety.
HTP:
RISB:
According to RISB, the client was reported to be maladjusted and the problem was in family
domain.
Case Formulation:
The client having an average physique came to a hospital named Safe Care Trust
International with crisis intervention for the treatment of substance use. After MSE, it was
observed that the client is well-groomed, neat and clean, conventional uniform, coordinated
psychomotor behavior, and consistent eye contact. Symptoms of auditory and visual hallucinations
were present along with paranoid and aggressive behavior. The choice of drug was Amphetamine
& Opioid. The client had no insight into his illness and was at the pre-contemplation stage of
motivation.
Treatment Plan:
comprehensive approach addressing both the immediate crisis and long-term recovery. Here's a
structured plan:
Modification of behavior: To manage the initial symptoms of illness and activities for behavior
modification, participate actively in all group sessions, and obey rules and regulations.
Family Involvement: Engage family members sensitively and educate them about psychosis and
Substance Abuse Treatment: Integrate substance abuse treatment alongside psychiatric care.
Offer counseling and support groups focused on addiction recovery, emphasizing culturally
Psychoeducation and Coping Skills: Provide psychoeducation about psychosis, its causes, and
management strategies to the individual and family. Teach coping skills and stress management
Long-Term Follow-Up and Support: Establish a long-term follow-up plan with regular
psychiatric appointments and ongoing support services. Ensure access to community resources and
teams including psychiatrists, psychologists, social workers, and community health workers.
outcomes.
professionals, family members, and community resources to address the complex needs of the
individual with amphetamine-induced psychosis within their cultural and socio-economic context.
Case 02
293.8 (F06.4)
Case Summary
The client S.E was referred to the psychiatric department of Benazir Bhutto Hospital from
medical department. Her complaints were high blood pressure, headache, anger issues, muscle
tension, irritability, excessive worry, fatigue, sadness and insomnia. The client has been suffering
from these symptoms since 10 years. HTP was applied on the client and on the basis of results it
was assumed that client had some features of anxiety. It is suggested that anxiety test should be
Identifying Information
Name S.E
Age 45 years.
Gender Female
Education Matric.
Residence Rawalpindi.
Informant Client.
Reason of Referral:
The client S.E was referred to the psychiatric department of Benazir Bhutto Hospital from
medical department. Her complaints were high blood pressure, headache, anger issues, muscle
tension, irritability, excessive worry, fatigue, sadness and insomnia. The client has been suffering
Presenting Complaints:
بلڈ پریش ر
کنٹول نہی ہوتا اور رس درد رہتا ےہ۔ نیند بھ نہی آت۔
The client reported about the complaints that were high blood pressure, headache, anger
issues, muscle tension, irritability, excessive worry, fatigue, sadness and insomnia. The client has
been suffering from these symptoms since 10 years and due to these issues the client has been
Personal History:
Birth History: She was born in Sindh with normal delivery and completed all the milestones in
Educational History: Client studied in a government school which was far away from her home
and her mother couldn’t afford a nearby private school so she send her to Islamabad with her uncle.
Social History: The client before the onset of disorder was very friendly, social and caring person.
She used to help her mother in cooking and other house chores. But after illness she got aggressive
Family History: Her father died when she was 5 years old. After her father’s death, client’s mother
started to work in her own field and in this way she was feeding her children. She came to her
uncle’s home for matriculation and living at that home she felt that her aunty was very strict with
her. At the age of 18 years she was married with a Navy officer and she moved to Karachi. Her
husband was of very suspicious and harsh with her. Being a wife she is suffering a lot. She has 5
children and they move to Rawalpindi. Her husband didn’t allowed any of his children to study
after matric. Client’s children didn’t respect her and they use to fight with her on minimal issues.
The client was very polite and caring to everyone before the onset of this order, she felt the
medical symptoms such as muscle tension, fatigue and insomnia after her marriage and and due to
His mother is sugar patient while his father had blood pressure issue . While no other
In order to assess client’s problem two types of assessment was carried out that were as follows:
Informal assessment:
Clinical interview
Formal assessment:
HTP
Clinical Interview:
Its professional face to face encounter with clinician; who ask questions about the client’s
problems, along about client’s reactions and all responses. Clinician collects all type of detail
information of client’s problem, lifestyle, feelings, emotions, relationships and other personal
history. (Comer,2004).clinical interview was conducted with the client to get detailed information
about her personal history; finding the cause and starting of the problem, her family history, her
relationship with her family and other relatives, her sexual history, educational information
,occupational, and social history. The client has no insight about her problem, and she was
motivated to seek treatment. During the initial interview session the client was not showing
cooperative behavior, but after building good rapport after 3 -4 sessions almost she opened up with
true responses provided by her. Onwards session information provided b yher started to get cleared
and major important details of client problem were obtained, helping to provide appropriate
treatment.
HTP was administered on the client to find out psychological, emotional, and mental health status
of client.
Result of HTP. Inquiry about the drawings shows that the client had drawn the picture of his child
and said that he is 20 years old, sad and wants freedom. She has drawn 2 years tree and she didn’t
related it with any specific tree. Inquiry about house indicated that she wants her own small house.
Qualitative interpretation. Drawing person first indicated preoccupation with self, narcissism or
hedonism. Drawing all pictures in the center of the page indicated rigidity.
House. Strong lines of walls indicated problems with anxiety need of protection. Extra attention
and shading on roof indicated extra attention to fantasy and ideation. Locked door indicated
psychological warmth in client’s home life. Pathways leading up to door indicate as sociability
Tree. Heavy lines or shadings indicate anxiety about one's self. Excessive attention to detail on the
leaves could be Obsessive Compulsive tendencies or anxiety. Heavily drawn bark on trunk
indicated anxiety and depression. Large trunk indicated more ego strength. Limbs moving up
indicated she is ambitious. Excessive branches indicated compensation or mania. Lack of roots
Person. Drawing opposite sex indicates emotional difficulties. Enlarge eyes indicate unusual
visual alertness. Over emphasis on nose shows sexual features. Close tight mouth shows denial of
needs. Omitted neck indicates impulsivity. Omission of abdominal area indicates severe
deterioration and hypochondrias. Absence of feet indicate child abuse, helplessness and loss of
Case Formulation:
On tree heavy lines or shadings, excessive attention on the leaves and heavily drawn bark
on trunk and heavy lines of walls of house indicated features of anxiety and it is related with the
client’s presenting complaints that are ‘excessive worry, muscle tension, irritability, fatigue and
insomnia’.
Treatment Plan:
(CBT) to address maladaptive thought patterns and behaviors. Exposure therapy helped the client
gradually confront her fears and reduce avoidance. Additionally, stress management techniques,
such as mindfulness and relaxation exercises, assisted in regulating her physiological arousal.
Medication was also considered for symptom management, in conjunction with psychotherapy.
Building social support and enhancing coping skills was integral to the client’s treatment plan to