Psycho-Diagnostic Report

Biodata:
Name of client: M.Y
Father’s name: M.Z
Gender: Male
Age: 55
Education: 7th grade
Marital status: Married
Examiner: M.R
Case no 3 Portfolio

Identifying Information:
M.Y is 55 years old, married male. His birth order is 4th. He has 1 younger brother and 1
sister. He has 3 elder brothers. His father and mother had died 1 year ago. His wife is a house
wife. He has 2 daughters and 2 sons. He owned a pan shop. 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 aggression, body pain,
loss of appetite and poor sleep. The client started smoking at the age of 25 and as time passes,
he become addicted to smoking. When his family came to know about his smoking, they
asked to quit it but according to client it was too late and I was unable to quit smoking. These
fights stressed him out and he started drink occasionally. His mother then decided to make
him marry so he will quit the drinking habit. But this did not work. The client’s family took
him to a hospital for treatment. There he was admitted for 2 months and then return home.
After few days, he again met his friends and they introduce him affime. As he was working
on pan shop whole day his family was unaware of his drug usage. Then one day his wife
caught him red handed when he was using affime at roof top. His wife took him to a rehab
center for treatment but the client discontinued the treatment in between and return to home.
This time he assured his family that he will quit the drugs but his friends visit him daily on
the shop and finally convinced him not to quit drugs. He was convinced that drugs give him
the peace that no one can give him.
According to client, after all these treatments and medicines etc. he was unable to quit drugs
and he was not getting that relaxation from affime so he started taking chars. He has been
using chars for 15 years. He increases the dosage day by day and now he was taking 2gm of
chars daily. His elder son took him to the rehab center this time and asked him to take proper
treatment and promised to quit drugs.
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:
(F12.20) Cannabis Use Disorder, severe,
in a 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 M.Y
Age 55
Presenting complaints Aggression
body pain
loss of appetite
poor sleep
Test administered Mental state examination

Tentative diagnosis (F12.20)

Cannabis Use Disorder, severe,
in a 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