Islamabad

Psychiatric clinic
& Rehabilitation center

HISTORY INTAKE

Demographics:

Name: Mohsin Raza

Age: 25

Gender: Male

D.O.B: 09-08-1996

Education: Bachelors (Discontinued)

Birth order: 2nd

Siblings: 3 (2 sisters, 1 brother)

Address: Sadiqabad Colony, House SA578, C-4, Street 11-c

City: Rawalpindi

Languages: Urdu, Punjabi, English

Religion: Islam

Marital Status: Unmarried

Emergency contact number: 0335-5112551

CNIC NO.: 3740552877981

Family System: Nuclear

Father’s name: Abdul Razzaq

Islamabad
Psychiatric clinic
& Rehabilitation center

Next to Kin:

Abdul Razzaq

Relationship to patient:

Father

Contact Number:

0335-5112551

Presenting Complaints:

Ice (09-06-2021- 09 07-2021) (½ gram – 1 gram daily)

Cannabis (occasionally 2018 – 2019)

Alcohol (occasionally in parties)

Cigarettes (4-5 years, from 2018) (6-7 cigarettes per day)

Interpersonal conflicts with father

Aggression (1 ½ months) (Physical and verbal aggression)

Sleep disturbances (9th June to 20th July)

Suspiciousness

Auditory and visual Hallucinations

Some depressive symptoms

Stubborn and demanding

Islamabad
Psychiatric clinic
& Rehabilitation center

History of Present illness:

According to the client, he started using ice from 9th of June 2021 because of his interpersonal
conflicts with his father. The client reported that once he reported the police about his father
being physically aggressive with him and his mother. Upon arriving of the police, his father
accused him of using drugs to divert the focus of the police from himself towards his son. The
police investigated the client and could not find any proof and the conflict was settled. The client
reported that his father accused him of using ice when he was not using it which became the
reason he started using ice to get a revenge on his father. He wanted to prove everything that his
father accused him of.

The client has been smoking cigarettes from 2018 due to stress and the conflicts with his father.
He used to smoke 6 to 7 cigarettes daily and the quantity increased according to his stress level.

Between 2018-2019, he started consuming cannabis in the form of cigarettes. He used it

occasionally in the presence of his friends.

He has also consumed alcohol occasionally in parties.

The client is stubborn and shows aggressive behavior towards his family members, physical as
well as verbal aggression. The client reported that he has never been involved in any fight
outside but has always been facing issues with his father. He is very suspicious about his father
and thinks that his father spies on him with the help of other people. He reported that his father
thinks that his friends got him involved in drugs.

After using ice for a month, the client experienced auditory and visual hallucinations for some
time. He reported that he used to hear someone calling him and sometimes heard azaan when it
was not being recited. He used to see someone covered in a white cloth in his house. He
experienced this feeling where he would think something and the next day, that thing would
actually happen.
Islamabad
Psychiatric clinic
& Rehabilitation center

Past Psychiatric History:

The client went to Military Hospital (MH) previously with same psychological and substance
abuse problems.

Medical History:

Nil

Previously Medication Used:

Nil

Family History:

Client’s both parents are alive. Their marital relationship is very unstable and the father of the
client also occasionally hits his wife. The client’s mother is 48 years old with blood pressure and
vertebral disc issues. Father is 55 years old and a Hepatitis C patient from last 20 years.
According to the client, his father’s relationship with his mother is very violent and sometimes
abusive as well but with other siblings, his relationship seems to be normal because they obey his
father whether he is right or wrong. The client’s relationship with his father is full of conflicts
because of his suspicious personality and behavior towards him. The client reported that his
uncles and aunts from his father’s family side are also not able to speak in front of his father
because of his indifferent personality.

Personal History:

Client’s birth was normal and achieved all the milestones on time. According to the client, he
was a careless child in his early childhood but remained good towards his friends. He started his
schooling at the age of 3 and was a good student who had good relationships with his teachers,
friends and classmates. The client reported that he completed his Matriculation at the age of 13
and 14. After that, he went to college but there he repeated his first year of intermediate twice
because of his poor result.
Islamabad
Psychiatric clinic
& Rehabilitation center

Afterwards, he got admission in Arid University in BS- IT. He was a good student in university
with a cgpa of more than 3.2. He completed his 6 semesters in university and discontinued his
studies in 7th semester because of loss of his interest. He wanted to pursue a career in media field
but his father was not impressed by it which is one of the reason of losing interest in his studies.

After discontinuing his university, he started attending bad gatherings and eventually involved in
drugs. According to the client, he and his father had been always arguing on different things
which led to him being stressed. Then he started using drugs to relieve his stress. Afterwards, his
focus directed on his real goals and started to work in that direction.

From 2016-2018, he worked as a helper under the supervision of a doctor. From 2019-2021, he
worked in Bol channel in Axact.

The client reported that he has a female friend and his family has major concerns with her. His
father suspected her of involving his son in drug abuse.

Drug History:

When did you start using drugs?

In 2018 in university.

Who provides you drugs and how do you buy?

Drug dealers (from Peshawar) and friends provide all the drugs.

What narcotics do you use and since how long?

Ice (09-06-2021- 09 07-2021) (½ gram – 1 gram daily)

Cannabis (occasionally 2018 – 2019)

Alcohol (occasionally in parties)

Cigarettes (4-5 years, from 2018) (3 cigarettes per day)

Islamabad
Psychiatric clinic
& Rehabilitation center

How often do you use drugs a day?

Ice (½ gram – 1 gram daily)

Cannabis (occasionally)

Alcohol (occasionally in parties)

Cigarettes (6-7 cigarettes per day)

In what situations you crave the drugs most?

In stressful situations, after having arguments with father and in the presence of his friends.

What was the reason you started using drugs?

The client reported that he started using drugs because of the stressful situations. According to
him, after losing interest in studies he got involved in drugs because of his friends and peers to
avoid stressful situation. He got involved in many arguments with his father at home which
became a main reason. He became very aggressive and violent towards his family members.

Forensic History and Conviction:

Nil

Psychosexual History:

The client reported that in 2016 he met a girl in Bahria Town and gradually developed friendship
with her. They both had been in a good relationship initially as friends. Gradually both
developed interest in each other and both involved in a relationship. They both got intimate
several times and developed sexual relationship among each other. The client reported that his
father did not approve of their relationship and suspected the girl that she also uses drugs and
made his son also do it. This factor also triggered his stress more. The client reported that the girl
got married on 19th March, 2021 but still they both were involved in each other (physically) even
after her
 Islamabad
Psychiatric clinic
& Rehabilitation center

marriage. According to him, the girl is not happy with her marriage and neither is her husband
which is why they were still in contact with each other.

Mental State Examination:

i. Appearance and behavior:

The client is a 25-year-old male. His hygiene was neither poor nor good. He was sitting on a
chair in a low posture, mood was very low and kept on blaming his father for everything. He was
very stressed from the beginning. He could not maintain eye contact. He was dressed according
to the place. Although he was cooperative throughout the session and shared all his details but
focused more on the interpersonal conflicts with his father.

ii. Mood:
Subjective: Normal
Objective: Low
 Anxiety:
Some symptoms present.
 Suicidal Ideation:
Present (brother reported)
 Idea to harm others:
Absent
iii. Psychotic Phenomenology

Paranoia Suspiciousness Delusions Idea of reference

Absent Present Absent Absent

 Hallucinations:
Present (auditory and visual)
 Thought Disorder:
 Islamabad
Psychiatric clinic
& Rehabilitation center

Absent
iv. Withdrawal symptoms:
Present (sleep and appetite disturbances)
v. Cognition:
Not intact
vi. Insight:
Into illness: Not intact
Into medication: Not intact
vii. Psychometrics:

TEST SCORE INTERPRETATION

BDI
BAI