Psycho-Diagnostic Report

Biodata:
Name of client: I.Z
Father’s name: Z.A
Gender: Male
Age: 31
Education:
Marital status: Married
Examiner: M.R
Case no 5 Portfolio

Identifying Information:
I.Z is 32 years old, married male. His birth order is 7th. He has 3 elder brothers and 3 sisters.
His father and mother are alive. His wife is a veterinary doctor. He is a wedding planner and
interior designer. He belongs to middle socio-economic status.

Referral source:
The client was referred for the purpose of assessment and management.

Presenting Complaints:

Interview Information:
The client was admitted to the clinic 1 month ago with complaints of body pain, loss of
appetite and poor sleep and need for drugs. Client started rikshaw driving in 2007 for income,
at that time he started smoking cigarettes. He worked hard but no one appreciates him which
hurt him emotionally and then he distant himself from family. To get rid of his stress and
loneliness, the client started to take chars. Then he struggled for the visa of Malaysia to learn
some skill and have his own business. He stayed in Malaysia for 7 years where he works and
also take chars. Living in that culture make him more comfortable using drugs. He also
started to drink at weekends. The client became addicted to chars and drink that after
returning to Pakistan he was unable to quit the drugs because of which family issues arise.
After some time, the client got married to his cousin 3 years ago and now they live
separately. His wife tries to refrain him from drugs but could not succeed. 3 months ago,
when the client started using Ice, he got allergy on skin as he continues to use it. At the end,
his wife took him to the clinic for treatment.

Psychological Assessment:
Informal:
Behavioral observation
Mental State Examination

Behavior during session:

The client’s expressions indicated sadness and unhappiness. Client was quite in the beginning
of the session but he was cooperative and express all his feelings and emotions. The client
maintained an eye contact and was answering in a proper way.

Psychological Evaluation:
According to mental status examination, his thoughts were generally logical and age
appropriate. Orientation of client was appropriate. He remembers all things about his
childhood. Client’s attention was appropriate. The client had insight of his problem. Over all
the mental state examination of client shows appropriate thought content, judgement and
abstract thinking.
Tentative diagnosis:
(F15.20)
Amphetamine-type substance, moderate,
In controlled environment.

Recommendations:
Medication dosages should be followed and should keep in continuous check so that client
could not skip the dose.
Deep breathing would help the client attain a feeling of relaxation.

Prognosis:
Client’s prognosis was good.
Treatment Plan:
Name of client I.Z
Age 32
Presenting complaints body pain
loss of appetite
poor sleep
need for drugs
Test administered Mental state examination

Tentative diagnosis (F15.20)

Amphetamine-type substance, moderate
In controlled environment.
Goals of therapy Short Term Goals:
Rapport building in order to make client comfortable,
to create trustworthy relationship between therapist
and client and to engage client in therapy.
Clinical Interview
Test Administration
Deep Breathing
For relaxation and anger management.
Cost benefit analysis:
It will be used to make the client learn about
advantages and disadvantages of drug use.
Craving Management Skills:
In this therapeutic approach, 5D technique will be used
which will be including
a. Delay
b. Deep breathing
c. Distract
d. Drinking water
e. Discuss
Group therapy:
a. To provide positive peer support and pressure
to abstain from substances of abuse
 b. As the client is socially active group therapy
will be affective for the client by attending
recovery group meetings.
Long Term Goals:
 Continuation of short-term goals
 Follow up sessions for monitoring client’s
performance
 Relapse prevention
 Termination
Main therapy Cognitive Behavioral Therapy
Group therapy

No. sessions planned 12

Initial 1-5
Middle 6-10
Termination 11-12