Contents

Introduction ................................................................................................................................................... 3
Substance Use Disorder ............................................................................................................................ 3
Substance-Induced Disorder ..................................................................................................................... 5
Substance Induced Disorder includes Substance Intoxication and Substance Withdrawal. Substance
Intoxication. .......................................................................................................................................... 5
Substance Withdrawal. ......................................................................................................................... 6
Cannabis Use Disorder .............................................................................................................................. 6
Diagnostic Criteria ..................................................................................................................................... 6
Comorbidity .............................................................................................................................................. 8
Cannabis Withdrawal ............................................................................................................................ 9
Differential Diagnosis .............................................................................................................................. 10
Opioid-Related Disorder ......................................................................................................................... 10
Diagnostic Criteria ............................................................................................................................... 10
Comorbidity ............................................................................................................................................ 12
Differential Diagnosis .............................................................................................................................. 13
Opioid Withdrawal .................................................................................................................................. 13
Case Identification ...................................................................................................................................... 14
Duration of Session ................................................................................................................................. 14
Referral ................................................................................................................................................... 14
Identifying Data....................................................................................................................................... 15
Presenting Complaints ................................................................................................................................ 16
By Client: ................................................................................................................................................. 16
By Informant: .......................................................................................................................................... 17
Symptoms ................................................................................................................................................... 17
Behavioral Observation............................................................................................................................... 18
Personal History .......................................................................................................................................... 18
History of present illness ............................................................................................................................ 20
1. Premorbid personality ........................................................................................................................ 21
2. Onset of the illness.............................................................................................................................. 21
3. Medical psychiatric condition ............................................................................................................. 21

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 Past sympatric history ............................................................................................................................. 21
Formal assessments .................................................................................................................................... 21
Mental Status Examination (MSE) .......................................................................................................... 22
Bender Gestalt Test (BGT)....................................................................................................................... 27
Rotter’s Incomplete Sentences Blank. .................................................................................................... 28
Hand test. ................................................................................................................................................ 31
Case Formulation ........................................................................................................................................ 33
Social Learning Theory ............................................................................................................................ 33
Adlerian Theory....................................................................................................................................... 34
Psychodynamic Theory. .......................................................................................................................... 36
Anxiety, according to Sigmund Freud. .................................................................................................... 36
Tentative Diagnose. .................................................................................................................................... 37
Therapeutic Recommendation ................................................................................................................... 37
Rational Emotive Behavioral Therapy. .................................................................................................... 37
Cognitive Behavioral Therapy. ................................................................................................................ 38
Drug Therapy. ......................................................................................................................................... 39
Family Therapy. ....................................................................................................................................... 39
Prognosis ..................................................................................................................................................... 40
References ..................................................................................................... Error! Bookmark not defined.

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Introduction

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.

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 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 3

4
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.

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

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.

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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: 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:

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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, andconduct

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,

8
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.

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.

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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).

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,

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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:

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).

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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.

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

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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., opioidinduced 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.

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.

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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.

Case Identification

Duration of Session

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

was approximately 1 and half hours span.

Referral

14
Client stated that he began treatment at Najjat Rehabilitation center in Rawalpindi one month

ago. He will discharge after 18 days and will sent to his village. The client was working in a shop

as a shopkeeper. There is also a man who is a client’s friend also works in a shop .One day his

friend offer him to dry some drug, which cause him to drug abuse and his father admitted him to

Najjat Rehabilitation center ,where he is still admitted.

Identifying Data

Name: X, Y, Z

Sex: Male

Age: 24 Years

Education: Matric

Occupation: Shopkeeper.

Monthly Income: 80,000.

Father’s Name: Mazhar Hussain.

Mother’s Name: Nasreen.

Father: Alive

Mother: Alive

Father’s Education: masters

Mother’s Education: Matric

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Father’s Occupation: Police Officer

Mother’s Occupation: House Wife.

No. of Sibling: 4.

No. of Brothers: Two.

No. of Sisters: One.

Step Relation: Nil.

Marital Status: UnMarried.

Birth Order: Client is 1st in Sibling of 4.

Place of Birth: Jhang Hospitl.

Place of Residence: Jhang.

Family System: Joint Family System.

Referral: Brother.

Religion: Islam.

Informant: Staff of Rehabilitation Centre.

Presenting Complaints

By Client:

‫هجھے اپٌے جسن هیں بہت درد هحسوش ہوتا ہے۔ ایک احساش ہے کہ هیرا چہرٍ خراب ہو رہا ہے۔ هیں اکثر اپٌا ًشہ اپٌے‬

16
‫پر پوری طرح ًہیں اترتا۔ اکثر لوگ غصے هیں آکر داًت پیسٌے لگتے ہیں اور ایسا لگتا ہے کہ وٍ ًاراض ہو جائیں گے۔‬

‫هیرے ایک برے قدم ًے هیری زًدگی برباد کر دی لیکي کوشش کریں کہ دوبارٍ ًہ آئیں اور اپٌی زًدگی خوشی سے‬

‫گساریں۔‬

By Informant:

When the client arrived for treatment he shows inappropriate behavior. He was easily irritated or

agitated by mild stimuli during his first days in the hospital. But later on, he becomes calm and

quiet due to medication. On the first few days, he complained that he couldn’t sleep and that if he

couldn’t take drug, he felt pain in his body, weakness, tingling in his hand. His condition has

changed .He is calm, humble and cooperative, and he tries listen to doctor.

Symptoms

Headache. ‫سر درد‬

I have pressure blood high have frequently .‫هجھے اکثر بلڈ پریشر ہائی رہتا ہے۔‬

Fatigue ‫تھکاوٹ‬

Aggressive Outbursts. ‫جارحاًہ حولے۔‬

Loss of Appetites. ‫بھوک هیں کوی۔‬

Dryness of mouth and throat .‫هٌہ اور گلے کا خشک ہوًا۔‬

Fluctuation of Mood .‫هساج کا اتار چڑھاؤ۔‬

Tingling in hand and feet .‫ہاتھ پاؤں هیں جھٌجھالہٹ۔‬

Feeling Alone.‫۔‬ .‫تٌہائی هحسوش کرًا‬

17
Irritability .‫چڑچڑاپي‬

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. 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

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

and hair. The client try to hide his conflict with his father. 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 strong eye contact.

Personal History

In 1998 ,the client was born in Jhang. He recalled his early development, say that he was sharp

and active. He always stood Ist in the class up to grade 5. He enjoyed playing games with his

friends. He took part in all activities. His mother is a house wife and his father is a retired army

18
officer. After grade 5 , the client shows no interest in studies, and passed his exam by cheating.

He belongs to a religious family and have a lot of knowledge about spiritualism. His father is

quiet strict and want him to study and work hard but he couldn’t do so and hardly complete his

matriculation.

The client has 3 more siblings and client has a great childhood with them. There

weren’t many really bad things happen to him. He described that he is the most beloved son of

his mother. His grandmother also loves him so much. But his father is extremely angry,

emotionless and powerful. He reported that he couldn’t fulfill his father’s dream as he wanted

him to become a successful officer.

The client has some clashes with his father but sometimes he avoid to disobeying him.

The client reported that he doesn’t want to be disrespectful to his father but his father behavior

provokes him to do so.

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 police 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 father’s bad behavior. He

claimed to have tried to study, but I was unable to do so. His friend's home have a financial issue

that he frequently worried about, and he smoked cigarettes and cannabis. We discussed every

19
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 22 years old,

and cigarettes became a habit for him.

Client stated that he began using cannabis more frequently when he was 22 years old.

He and his friend 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 24. He claimed that when he did not take the drug, he experienced pain throughout his

body. He was discharged after 1 month. He abandoned the drug.

The client reported that his friends are also drug addicted, they all drink alcohol but

he never ever drinks alcohol. The client reported he is not interested in marriage. But if his

parent enforces him to get married then he will. The client reported after getting out from the

rehabilitation center, he will go to Dubai, and started a business of real estate with his cousin.

The client’s also reported that he wants to make good relation with everyone. He also

claimed that he want to get rid from this center.

History of present illness

At his initial age up to grade 5 the client was a good student .But after that the client shows no

interest in study. He have some friends along with he spends his whole time. He have done his

matriculation, and from that he quit his studies. His father wanted him to continue his study but

20
he could not do that. Then he opened his own shop, where he get opportunity to use a drug at the

age of 22. No hallucinations were reported of any category.

1. Premorbid personality

The behavioral change occurred in client when he was in 6th class. He was a person who lives in

company of limited friends who admire him. He had mild conflicted relation with his father. He

used to be very much sensitive to what others said to him but he was aggressive in reaction.

2. Onset of the illness

The client started feeling to be upset, anxious, depressed and being that more negative 24

months ago, when he realized to be left alone completely by his family members will stop the

irritable, aggressive attitude was noticed to be experience since each 20. The client reported the

same issues for a continuous till now. That relapse for drug was reported.

3. Medical psychiatric condition

There is no medical history reported by client.

Past psychiatric history

The client took cannabis from one and half year. Then he started opioid, and his father caught

him red handed. Then he was admitted by his father to Najjat rehabilitation center for amount.

Client reported that he is admitted for the first time in rehabilitation center.

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

21
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. Bendar Gestalt Test(BGT).

3. Rotter’s Incomplete Sentence Blank (RISB).

4. Hand test.

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.

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.

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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 27 but originally he was of 24.

 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: Strong 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 and evasive

responses while performing the RISB test with reduced intensity. The overall attitude

was more open and cooperative.

23
  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 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.

 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.

24
  Mood (Anhedonic , Grieving, Dysphoric, Depressed): Client reported that he did not

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

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 good.

 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 good 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.

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.

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 Delusion: Nil.

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

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

were observed.

 Obsession: Nil

 Preoccupation (Pre entangled thoughts): Client was preoccupied with his father, as well

as his negative past experience and relapsed.

 Suicidal Ideation: Nil

 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.

F.) Perceptual Abnormalities.

 Hallucination (Auditory Hallucination &Visual Hallucination): Nil

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 more focused and less 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:

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  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.

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 nonverbal, performance test

widely used psychological instrument in the field of clinical psychology (Sundberg, 1961, P.79).

Bender Gestalt test differentiate into broad categories; 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

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neurological deficits. Individual who have suffered a traumatic brain injury may be given the

Bender Gestalt as part of neuropsychological measures, or test.

Scoring

Total Score = 13.

Subject Score= 9.

Time: 13 minutes

Interpretation

The results shows that subject obtained a score of 9 and total score is 12. The result indicates that

the subject has strong brain impairment.

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…..”

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.

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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.

Response Category Corresponding Score Obtained Score

Positive Response

P3 0 7*0=0

P2 1 7*1=7

P1 2 4*2=8

Neutral Response

N 3 2*3=6

Conflict Response

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C1 4 5*4=20

C2 5 5*5=25

C3 6 10*6=60

Cut off score: 135

Subject’s Score: 7+8+6+20+25+60=126.

Time: 15 minutes.

Subject score is 126 and it indicates that client personality is well adjusted . Additionally, he has

good interaction with society . He is 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.

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

30
society typically perceives him. In other responses, his negative ideas about society can also be

seen.

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.

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 selfimage due to

certain reason which includes his childhood experience especially. He can be seen as considering

himself for his experience and also has responded in a way illustrating his very bright future.

Conclusion

The subject could be characterized as having 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 126 out of 135 which indicates that subject fits in society.

Hand test.

The Hand Test is a projective technique that utilizes ten unbound 3.5 x 45 inch cards, nine with

simple line drawings of single hands and one blank card, to measure how the viewer interprets

what each hand is doing (the blank card is left to the imagination of viewer). Verbal responses

are given or “projected” by the viewer, and the results are reconted,scored and interpreted by the

administrator. First developed in the early 1960s in reaction to 1 professional controversy over

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projective techniques like the Rorschach, Wagner presented the Hand Test as a "starting point"

or "narrow band" instrument that "does not necessarity measure all major aspects of personality

but does assess the individual's behavioral tendencies" (Wagner. 1983). For over forty years, this

method has been proven to be effective in measuring overt andAggressive behavior. According

to Western Psychological Services, the Hand Test has been administered to well over one million

people (Wagner, 1983). The client has shown high scores in the areas of maladjustment,

withdrawal and environmental aspects. The client has scored high in addition to pathological

dynamics.

Example:

‫یہ چاًشا هار رہا ہے۔‬

Slapping is a very obvious action showing the tendency of aggression and humiliating other

serson against, which depicts the same pattern in client’s behavior or personality.

‫پاکی هار رہا ہے۔‬

Farming any person with nails is the response showing client’s hostile behavior and disturbed or

social tendency for other individuals he might be imagining during response.

‫ی شدٍ کر رہا ہے کسی اور حیات کی کی طرف‬

He clients interest and defensive behavior (for example self laughing, delayed response) during

is response shows his sexual tendencies.

‫۔‬ ‫ تو اى هیں رہا ہے‬،‫تیار کیا اور اور ا ہے‬

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This is a response showing perception of impairment or crippled stimulus. The response shows

client’s focus in the area of being or getting physically handicap or being damaged by or with

something or someone.

‫۔‬ ‫یہ دل کو دبارہا ہے‬

The response is very gross or insignificant, rather disturbing to be heard or read which is

probably a sign of very pathological approach. Because usually squeezing a heart can never be

characterized as an organized or a significant response.

Case Formulation

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 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

33
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

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

drugs.

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

34
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 50 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 first birth. Everyone admired him and he

is powerful , and spoiled he took advantage of his power and might be take a wrong decision for

himself.

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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, which

influenced his adult life.

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.

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 wellbeing, as

when a ferocious-looking dog appears from around the corner. The other two types are derived

36
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.

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. The client's history of academic issues

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

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

37
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,

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.

38
 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.

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 56 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

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

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.

39
 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.

Prognosis

The client is an inpatient, the therapeutic methodology and care may be a potential source test his

ssues but as the client himself is not ready to accept the treatment properly and in intended to

relapse again, if he gets opportunity. There are not much chances of his complete ecovery

because after the duration of 22 months, elient himself reports to be facing more complications

and intensity in problems because of treatment he is given so long. So if it does happen to treat

him, it will minimum take 2 years for his complete recovery if all the measures and attention is

under consideration. The client should be potentially prepared mentally for treatment in that

case. Because since he won’t be ready for his treatment he can’t be cured from what issues he is

having.

40
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King, A.M., Johnson, S.L. Davison G.C., & Neale, J.M., (2009). Abnormal Psychology.

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

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

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

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