Case 1-

Poly substance abuse disorder

Name:

Javeria Afzal

ID:

Bc200203545

Date of submission:
10- 03-2022

University name:
Virtual university of Pakistan

Acknowledgement:

I am truly thankful to my instructor Miss AMNA Haider.I am also thankful to my internship

instructor miss NASREEN. Both helped me to develop my understanding about report and
helped to complete it.

Executive summary:

Client is 22 years old, boy and referred to psychologist for the assessment and
management of behavioral problems. Client belongs to upper middle class .he was
studying DPT .He is addict with Alcohol, Hash, Heroine, ice for last 8 years. He always used
to spend time with friends because he lived in hostel. He is admitted in Nishan rehab for
his addiction. Client went through a complete session of withdrawal and then a complete
behavioral and mental assessment and management of these problems. different
assessment tools (formal and informal, physical and psychological symptom
chart ,behavioral rating of symptoms ,MSE ,MMSEDAST,MAST).were applied on client to
find the cause of problem .then a complete management plan was devised and applied on
client.as psycho-education ,MET,ATS,CBT were used.

Background information/History-

Name-M.U

Gender-Male

Age-22

Education-DPT (in 3rd year)

Birth order-last

Number of siblings-5 (3 Sisters two brothers)

Marital status-unmarried

Occupation-unemployed
Date of admission-3-Jan-2022

Informant-

Referred by brother

Main reasons for referral-

Client was referred for psychological assessment and management.

Presenting complaints Duration

Constipation ka msla mje detox se ha.phly 2 week

bh rhta tha during addiction.

Stress tb se jb se rehab ma admit hua hun. 2 week

Body stiffness hui jb detox hua. Withdrawal 1 week

ka bad se muscle ma pain hua.

Sleep disturbance hui jb drugs chori. 2 weeks

Loss of appetite, drugs ma khaane ka pta nh 3 weeks

rhta tha

History of present illness-

Now, he was suffering from Post withdrawal, post effects of leaving drugs, physical
weakness like body stiffness post effects of crystal myth, low speed of walking, talking.
initially problem was started in college life during 1st year, in college he took
cigarette ,cannabis or Alcohol.in medical college Bahawalpur when he start taking ice to
cope with the stress of studies.

in predisposing factors, the unhealthy diet, use of cigarette, using cross drugs, emotionally
weak personality are the main causes of predisposing factors.

the precipitating factors that trigger the client to take the emotionally blackmailed by
peers group. Fear of loose of friends or gathering (social circle), absence of guidance from
family about addiction and bad environment of hostel in which all roommates takes drugs
are the precipitating causes of drugs.

the journey of client from abuser to addiction is 8 years, but problem become serious in
1st two years of Medical college. the factors that maintain the problem is unawareness
about addiction(that it is a progressive or chronic disease not a habit), bad company ,
emotional attachment with peer group(dependency),weak will power, relapses when he
left drug on mother pressure, lack of sobriety in personality are the main causes of
maintaining illness.

 Family History-
Father is died. Cause of death is Paralysis. He was paralyzed from last 29 years, he was not
doing anything. He was inter pass. He was facing serious physical problem, like paralysis of
left side of body. He had no psychological problem. He was psychologically a healthy
person. He had a strong personality. He was considered as a nice person and loved by his
children. He had a good father son relationship.He had a loving caring relationship with
client. Client spend 17 years with his father and he considered his father extremely loving
or understanding personality.

Client reported that his parent have a very good relation. He had seen a peaceful
environment in his family. Mother is alive and uneducated. She had a good health,
sometime feels pain in knees. She had no psychological issues. She had a good nature.
Understand her children and close to her children share very good bond with sons and
daughter. Loving caring personality. Unite the family members after husband death.

Client has a good relationship with mother. His mother understands him cared him. He
first told to her mother about his addiction due to closeness with the mother. His mother
had a good relationship with his husband. Client reported that his mother is very caring
about his father, and they were ideal couple. He spent large part of life in hostel, but he
always receive love from parents and warm environment in his house. Number of siblings
is 5. 2 brothers and 3 sisters. Client Birth order is last Born as a healthy child. Had good
health before addiction.

Had a loving or caring relationship with siblings. Close to brother a lot, have a good
understanding with brother or sisters. He shared a good bond with his family.as his 3
sisters are married and father are died he is more close to her mother or brother. He had a
healthy relationship with his family.

Personal history-

Birth-born as a normal child.no complication during pregnancy. He was a healthy child.

Developmental milestone-

He does not remember about his developmental milestone like when he start walking or
speaking. He does not remember any child story.

Medical history-

As a young child he does not suffered from any seasonal disease. When he admit to hostel,
due to fast food or unhealthy died he faced the Appendix problem.

Traumatic experience-

He faced no traumatic experience in his childhood or adulthood. He lived in a healthy

environment.

Schooling-

He start his schooling from the age of 5.he studied in Government boy’s high school, Malsi.
He easily adjust in schooling. Completed his schooling in his hometown from PG to matric.
He was good performer in school. He does not face any shifting or adjustment issues in
school. Top in every class. Gained 917 marks in matric or in FSC 740.he performed in extra
-curricular activities like speech. He had a good relationship with his teachers.as a bright
student teachers liked him. He was an active, energetic boy. He faced no such bullying
issues in school. client reported that he was very simple or naive personality, everybody
liked him.

Adolescence-

Age of puberty start from 12 years. He had not no proper information regarding puberty.
He was introduced to sex through his friends.

Pre -morbid personality-

Social interest-

As a young boy or good person he actively engage in social interest, loved to belong with
the group either in family, cousin group or in college group. He shared good bond with his
extended family. Visit his uncles or aunties. He showed positive attitude to his
surroundings and respect to his elders.

Social relationships-

He showed positive or respectable attitude towards his distant relatives or people linked
to his life.

Mood-

Client reported no mood swings .he said he had a composed personality or quite
personality. Like his mood not affected his actions. During the time period of addiction he
did not became irritable or abusive. Just become isolated.

Moral and religious values-

He reported that he prayed 5 times in a day. But he does not know the moral basic values
of Halal or Haram. Client reported that no one told him that Drugs are Haram in Islam. He
followed moral values like afraid of hurting anyone. Provide support to his friends.

Habits-

He loved to go to gym and work on his body. He loved to spend time on mobile and to play
games on mobile. He does not like cricket. More time spend in gym.

Reactions to stress-

Client reported that he become isolated in stress situation. He became quite or showed no
response or cut off from the loved ones.in stress he faced uncontrollable thought but he
does not showed that to others.

Smoking/drug abuse-

Client reported that he become user of cigarette in 1 st year. After some time he increases
the dose and take 20 packs of cigarette per day and become abuser of it. After cigarette
he start taking ice (5-6gram easily take) per day. He takes ice because he had to stay
active in night for his exam preparation. He reported that he left ice after exams. Alcohol
takes for some time period, he does not like cannabis, because this drug made him slow.
The cycle of addiction start from cigarette to using multiple substance abuse.6 years he
continuously take drugs (but left Alcohol in 2017).in the end of 2021 his physical health
become affected a lot due to taking of heroine. He start becoming weak, all time in
sleeping mood, cut off with the family and mostly isolated and crying.
Psychological complaint-

As client reported-

 Daamag bht dabao ka sikaar ha.

 tanha mehsos huta ha.

 irritability sometime huti han.

 Kch smhj nh ata zindgi ma kia krun.

 Tension rhte ha agee kia hu ga.

Previous and present psychological problem.

Client reported that he was not a lonely person previously ,he enjoy in company.he was in
good mental state,and he has goal about education.but after taking drug he lost interest
in family,study.keeping himself isolated,and thinking too much about
future,uncontrollable thoughts are main problems.but after taking drugs these problems
arise and now he does not know how to manage it.

Assessment

 Informal assessment was carried out through-

1- Physical and psychological symptom chart

2-Behavioral rating of symptom.

3-Mental status examination.

 Subjective rating-

Symptom Rating

Stiffed body 07
muscle

Joint pain 05
fatigue

insomnia 08

Loss of appetite 05

hopelessness 09

Distress due to 08
hospital anxiety

irritability 08

stubborn 06

Mental status examination-

Appearance-
Sitting posture-

Sit straight and erect body posture.

Facial features-

 Hair color is brown.

 Texture is strong body, tall or good looking.

Styling and grooming-

Well-groomed personality, and like simple styles

Height-5/7

Weight-68

Body shape -

tall , strong.

Cleanliness-

He reported that he takes care of cleaning. Takes shower or change clothes. He takes care
of hygiene.

Neatness-client showed neatness, he takes shower before session or change clothes.

Clothing and dressing-

He had a sense of dressing. He takes care of his clothing.

Level of eye contact-

He maintained good eye contact. Showed comfortable and confident eye contact.

Eye movement-

Client reported different eye movement, like when remembering past eyes showed pain or
regret.

Degree of friendliness-

He trust counselor and had a moderate level of friendliness.

Apparent age-

He looks 22 years old man.

Mannerism-

He is a nice person. Talk politely or showed good mannerism in sitting talking or choosing
words.

Speech-

Volume of speech-

During my early session with client he had slow rate of speech, now he entered in 8 week
of recovery he a good normal rate of speech. Now he talk like a normal person.
 Shuttering/stammering-

He does not show stammering or shuttering.in early weak of recovery he takes time to
speak, but speak clearly .but now it improved a lot as his recovery period progressed.

Mood and Affect-

Thoughts-

 Stream of thought is disturbing. Sometime had positive thoughts and sometime

negative thoughts come in mind. Client reported that he had a control to overcome
his thought and replace it with the optimistic view .he said that now he adopted the
philosophy of Move on. He said he does not want to keep him disturbing state of
mind. Insight has developed in me to keep myself optimistic.

Thought content-

Delusion-

Do you feel that people are against you?

NH mje NH lgta ka log mere bre ma bat kr rhe hain.yhan sb mere dost hain.

Hallucinations:

Do you hear voices that others cannot or seen things that others are not seen?

NH mje Na aese awazain Ur Na shaklain dekhaie dete han.

Orientation:

Orientation (date)

Aj 15 date ha

todays month?

Ya January ka month ha

Orientation (Place)

Ya aik rehab center ha.

Orientation (Person):

What’s your name?

mera name usama ha.

Memory:

Remote memory:

where you were born?

Ma malsi ma peda hua.

Recent Past Memory:

which program you watch on tv today?

Ertugrul-ghazi
Recent Memory
repeat these words,chair,glass,pen

Client repeated the exact word accurately

General information/intelligence:
General knowledge questions
2+5=7
Insight:
whats the nature of your disease?
Ma aik chronic bemari ma hun.jo manage kr ka ma thk rh skta hun.ma apni
bemari ka mechanism samhj ke,or emotionally strong hu kr relapses se bch skta
hun,ur recovery m rh sktahun.apni cravings or thoughts par qabu pa kr m thkk
hu skta hun.

Formal assessment-
Formal assessment include diagnostic personality test ant personality test.

Formal assessment carried out through

 Drug abuse screening test(DAST)
 Mini mental state examination(MMSE)
 SMAST(short michighan alcohol screening test)
 Hospital anxiety and depression test(HADS)
 Beck depression inventory
 Penn state worry questionnaire

 DAST(drug abuse screening test)

DAST consing of questions about patients drug use during the past 12
months.it includes 28 questions which had yes or no options which indicated
for making yes score (1)
Or no score 0.

Quantitative analysis of DAST-

Total number ofitems-28

Number of yes responses-25
Number of no responses-3

Qualitative analysis of DAST-

Over 12 is definitely a substance abuse problems. And client scored 15 yes

responses which clearly means substance abuse.

 Mini-mental status examination(MMSE)

Mmse is a30 point questionnaire that is used extensively in clinical and
research settings to measure cognitive impairment.it is also used to measure the
severity of cognitive impairment and to follow the course of cognitive changes
in an individual over time, thus making it an effective way to document an
individuals response to treatment.
The client scored 24-30 which indicate no cognitive impairment.

 HADS(hospital anxiety and depression test)

HADS is a 14 item measure designed to assess anxiety and depression
symptoms in medical patients, with emphasis on reducing the impact of
physical illness on the total score. Depression items focus on anhedonic
symptoms of depression. Items are rated on 4-point severity scale. Thus HADS
produces two scale one for (HADS -A), and one for (HADS-D), differentiating
the two state.

Quantitative analysis of HADS

Total no of items-14
Anxiety items-05
Depression items-09

Qualitative analysis of HADS-

Zigmond and snaith created this outcome measure specifically to avoid reliance
on aspects of common somatic symptoms of illness, like fatigue, insomnia and
hypersomnia.a tool was created for the detection of anxiety and depression in
people with physical health problems.
A number of researchers have explored HADS data to establish the cut-off
points for case of anxiety and depression.Anxiety scoring is 13,which shows
clinical caseness while depression is 11.Client is more closed to depression
symptoms.

 SMAST (short michigan Alcohol screening test)

SMAST is a 13-item questionnaire.developed for Alcoholism screening
test. SMAST score 4 0r more shows potential Alcohol abuse reported.a full
assessment is required.

 MMSE mini-mental state examination-

This test showed the score of client 25-30,which means questionably
significant,and formal assessment of cognition may be valuable.

 Beck depression inventory-

BDI is a 21 item depression inventory.Client reported the score of 21-
30.level of depression is moderate.

Burners depression checklist-

A 25 item questionnaire to measure about thoughts and feelings,physical
symptoms.level of depression is from 51-75,which shows severe depression.
Diagnosis-
According to DSM-5 the client is diagnosed with poly substance abuse disorder
moderate 304.80(F18.10)

Diagnosis-
According to DSM-5 the client is diagnosed with poly substance abuse disorder
moderate 304.80(F18.10)
Prognosis:

Client recovery is satisfactory.

Recovery is satisfactory, and progressive day by day.in the 1st month of
treatment he was slow rate of speech or walk. Or weak physically or mentally.
but as the recovery period progressed he start taking group therapy or
individual session.it was difficult for him to attend the session, but now he admit
that that was all fruitful. Or helped him to understand the mechanism of his
disease. Start sharing his experience in group session. now as 1 month is
progressed, he start accepting addiction as chronic illness, and insight developed
to manage it by focusing of craving, shifting of thought process by taking
shower, and talking with room -mate or learning of how to avoid relapse, or
fulfilling his emotional bank account.

 
Management and Treatment:
 Pharmacological
Different drug therapies applied to client during his withdrawal session.
 Psychological/psychotherapy
During treatment the psychological therapies are used are

1-CBT
2-12-steps of recovery model.

CBT techniques that are applied on client are-

 Self-diagnose-
Helped him to diagnose you own problem, disturbing thoughts or emotions. Your
own manager of life.to cope with stressful situation.

 Relaxation training. Apply progressive muscle relaxation technique.

 Calming technique
 My thought diary
CBT intervention for skills training that applied on client
 Problem solving worksheet.
 Weekly activity schedule.
 Self-management plan worksheet.
 Monitoring early warning sign worksheet.
 Increasing motivation for psychological treatment.
12-steps of recovery model which emphasize on acceptance and spirituality.

Follow up Plans 
 In follow up plan continue same treatment. Enhancing on learning the CBT
technique.
 New orders(ordering new medication according to the condition of patient)
 Referral
 Discharge plan
On follow ups implementation on recovery plan.

Addiction Recovery Plan

1- Working on Personal triggers.

2-Ways I can practice self-care.

3-Emotional coping skills I want to learn

4-Relapse prevention strategies I can practice:

 1.When I feel the urge to use or experience a craving, I will call my counselor
 2.I will attend meetings at a 12-step program every week (I won’t miss these
meetings)
Suggestion and recommendation-
There was some barriers supporting a less favorable environment for the client as
less professional and individual care and treating them in same way .family situation
is also hurdle that need to be sort out by hospital follow ups to create more care to
the client. There was not a suitable management plan for client to done with specific
things.
Case formulation-
Client is 22 years old boy. since his childhood he does not seen any bad environment
between their parents. he had seen a peaceful environment. client belongs to a wealthy
family or his brother bears his expenses. he had in contact with bad company when
moved from MELASI to Multan, in college. client was feeling worry about future life
choices, or his emotional weakness. his sleep and appetite was also decreased. due to
stress or memory lost in 1 month he does not properly concentrate on his work.

1-
The use of illicit psychoactive substances is not a minority activity among young
people in the UK. Results from the most recent British crime survey show that
some 50% of young people between the ages of 16-24 years have used
Illicit drug on at least one occasion in their lives (lifetime prevalence). (Ramsay and
Partridge.1999).
2-
274 million people used illicit substances at least once in 2014.source UNODC world
drug report 2016.new york.united nations
 Summary of case formulation

Predisposing factors include Bad company,anxious personality.Precipitating

factors include bad company Effects of drug abuse and Fear of loss of social
circle.Maintaining factors Bad company Absence of awareness about
addiction in family.Protective factors are Parental care Right company
Rehabilitation suitable environment.
Appendix-
 Case 2-

substance abuse disorder and anxiety disorder

Name-

Javeria Afzal

ID-

Bc200203545

Date of submission-

10- 03-2022

University name-

Virtual university of Pakistan

Acknowledgement-
I am truly thankful to my instructor Miss AMNA haider.I am also thankful to my internship
instructor miss NASREEN. Both helped me to develop my understanding about report and
helped to complete it.

Executive summary-

Client is 19 years old, boy and referred to psychologist for the assessment and
management of behavioral problems. Client belongs to a upper class. He was studying in
FSC.he is addict with Alcohol,hash,heroine,ice for last 5 years. He always used to spend
time with friends .he is admitted in Nishan rehab for his addiction. Client went through a
complete session of withdrawal and then a complete behavioral and mental assessment
and management of these problems. Different assessment tools (formal and informal,
physical and psychological symptom chart, behavirol rating of symptoms, MSE, MMSEDAST,
MAST),Beck depression anxiety were applied on client to find the cause of problem. Then a
complete management plan was devised and applied on client. Then CBT, REBT were applied
on client.

Background information/History-

Name-D.N

Gender-Male

Age-19

Education-FSC

Birth order-last

Number of siblings-5 (2 sisters two brothers)

Marital status-unmarried

Occupation-unemployed

Date of admission-3-Jan-2022

Informant-

Referred by brother

Main reasons for referral-

Client was referred for psychological assessment and management.

Presenting complaints Duration

Constipation ka msla mje detox se ha.phly 3week

bh rhta tha during addiction.

Anxiety tb se jb se rehab ma admit hua hun. 6-8 week

Body stiffness hui jb detox hua. Withdrawal 1 week
ka bd se muscle ma pain hua.

Sleep disturbance hui jb drugs chori. 2 weeks

Loss of appetite, drugs ma khaane ka pta nh 3 weeks

rhta tha

Allergy reactions bh hue face par drugs Ki 2 weeks

waja se

History of present illness-

Now, he was suffering from post-withdrawal, post effects of leaving drugs, physical
weakness like body stiffness. Initially problem was started in 15 years of age. He took
cigarette, cannabis or Alcohol.

in predisposing factors, the unhealthy diet, use of cigarette or other substances, bad
company, parental negligence weak personality are the main causes of predisposing
factors.

The precipitating factors that trigger the client to take the emotionally blackmailed by
peers group. Fear of loose of friends or gathering (social circle), absence of guidance from
family about addiction and bad environment.

the factors that maintain the problem is unawareness about addiction(that it is a

progressive or chronic disease not a habit), bad company , emotional attachment with
peer group(dependency),weak will power, relapses when he left drug on father pressure,
lack of sobriety in personality are the main causes of maintaining illness.

Family History-

Father is alive. He is advocate. He was physically and psychologically a healthy person. He

had a strong personality. He was considered as a nice person and loved by his children. He
had a good father son relationship.He had a loving caring relationship with client. He
considered his father extremely loving or understanding personality.

Client reported that his parent have a very good relation. He had seen a peaceful
environment in his family. Mother is died due to cancer. Understand her children and
close His mother had a good relationship with his husband. Client reported that his mother
is very caring about his father, and they were ideal couple. Number of siblings is 5. 2
brothers and 3 sisters. Client Birth order is last Born as a healthy child. Had good health
before addiction.

Had a loving or caring relationship with siblings. Close to brother a lot, have a good
understanding with brother or sisters. He shared a good bond with his family. He had a
healthy relationship with his family.

Personal history-

Birth-born as a normal child.no complication during pregnancy. He was a healthy child.

Developmental milestone-

He does not remember about his developmental milestone like when he start walking or
speaking. he does not remember any child story.
Medical history-

As a young child he does not suffered from any seasonal disease. When he admit to hostel,
due to fast food or unhealthy died he faced the Appendix problem.

Traumatic experience-

He faced no traumatic experience in his childhood or adulthood. He lived in a healthy

environment.

Schooling-

He start his schooling from the age of 5.he studied in Nishat boys’ high school, Multan. He
easily adjust in schooling. Completed his schooling in his hometown from PG to matric. He
was good performer in school. He does not face any shifting or adjustment issues in
school. Top in every class. Gained 914marks in matric. He performed in extra -curricular
activities like cricket, table-tennis. He had a good relationship with his teachers.as a bright
student teachers liked him. He was an active, energetic boy. He faced no such bullying
issues in school. Client reported that he was very energetic personality, everybody liked
him.

Adolescence-

Age of puberty start from 12 years. He had not no proper information regarding puberty.
He was introduced to sex through his friends.

Pre -morbid personality-

Social interest-

As a young boy or good person he actively engage in social interest, loved to belong with
the group either in family, cousin group or in college group. He shared good bond with his
extended family. Visit his uncles or aunties. He showed positive attitude to his
surroundings and respect to his elders.

Social relationships-

He showed positive or respectable attitude towards his distant relatives or people linked
to his life.

Mood-

Client reported mood swings .he said he had a moody, demanding personality. During the
time period of addiction he did became irritable or anxious.

Moral and religious values-

He reported that he prayed 5 times in a day. But he does not know the moral basic values
of Hala or Haram. Client reported that no one told him that Drugs are Haram in Islam. But
he provide support to his friends.

Habits-

He loved to go to gym and clubs. He loved to spend time on mobile and to play cricket,
table-tennis.

Reactions to stress-
Client reported that he become irritable, or restless in anxious situation. he became
frightened or cut off from the loved ones.in that state he faced uncontrollable thought .

Smoking/drug abuse-

Client reported that he become user of cigarette in 8 grade. After some time he increases
the dose and take 20 or more packs of cigarette per day in a friends gathering and
become abuser of it. after cigarette he start taking heroine(5-6gram easily takes in a
day)reported that he also takes Alcohol in energy drink, and also drink in liters, he does
not like cannabis, because this drug made him slow, only takes for 3 month .he
simultaneously take ice or cannabis, client reported that Ice made him energetic or
cannabis made him slow. He preferred ice and takes it in huge amount.

Drug and Alcohol history-

Client start taking cigarette in the age of 15. He initially takes one to 5 cigarette in a friends
gathering, but after some time it increased and he takes 20 packs or more than 20 packs
in a day. He had lot of money, for taking drugs he buy a home with his friends where he
used all sorts of substances. He start taking cannabis (used very low quantity or for 3
months) or ice used for a longer time period that affected him physically made him
allergic. Client reported that ice increase his dopamine, made laughed more than normal
person or energetic. He was still using ice before admitting to Rehab, and in Rehab test,
this was reported that he takes crystal myth in large quantity. He also used Alcohol in
bars mixed with energy drinks. Using substances made his personality more anxious.

Psychological complaints-

As client reported-

 Daamag ma bht thoughts atee Han.

 tanha mehsos huta ha.

 Irritability besakoon rhtu hun.

 Koch smhj NH ata zindgi ma kia krun.

 Tension rhte ha agee kia hu ga.

Previous and present psychological problem.

Client reported that he was not a lonely person previously, he enjoy in company. He was in
good mental state, and he has goal about education. But after taking drug he lost interest
in family, study. Keeping himself isolated, and thinking too much about future,
uncontrollable thoughts are main problems. But after taking drugs these problems arise
and now he does not know how to manage it.

Assessment

 Informal assessment was carried out through-

1- Physical and psychological symptom chart (Subjective rating)

2-Behavioral rating of symptom.

3-Mental status examination.

 Subjective rating

Symptom Rating

Stiffed body 07
muscle

Joint pain 04
fatigue

insomnia 08

Loss of appetite 05

hopelessness 09

Distress due to 09
hospital anxiety

irritability 09

stubborn 06

Formal Assessment-

Formal assessment carried out through Diagnostic assessment test and Personality test

1. Mental status examination.

Appearance-

Sitting posture-

Sitting posture is not composed, continuously moving and do not sit calmly.

Facial features-

 Hair color is black

 Texture-

Tall, strong body features

Styling and grooming-

Well -groomed personality, and like styles or adopt fashion.

Height-5/11

Weight-80

Body shape -tall, strong.

Cleanliness-

He reported that now he takes care of cleanliness .takes shower or change clothes. He
takes care of hygiene.

Neatness-client showed neatness, he takes shower before session or properly dressed.

Clothing and dressing-

He had a sense of dressing. He takes care of his clothing, or styles

Level of eye contact-

He maintained good eye contact. Showed comfortableness with the counselor and
confident eye contact.

Eye movement-

Client reported different eye movement, like when remembering past eyes showed pain or
regret. Rapid eye movement when describing past events.

Degree of friendliness-

He trust counselor and had a moderate level of friendliness.

Apparent age-

He looks 19 years old man.

Mannerism-

He showed mannerism of talking. Talk politely or showed good mannerism not being
aggressive.

Speech-

Volume of speech-

Client had rapid volume of speech. Talk like telling a story in one go. Describe events
rapidly.

Shuttering/stammering-

He does not stutter or stammering during speech.

Mood and Affect-

Thoughts-

 Stream of thought is mixed .some time had overly excited or positive thoughts and
sometime negative or excessive worried thoughts come in mind. He said he overly
thinks about events that will happened in future, or become anxious about that, like
time period of recovery in rehab.
Thought content-

Delusions-

Is you thought people talking about you, or your relatives are against you or you belonged
to special noble personality?

NH mje aesa NH lgta thaka koi mere khilaf bt kr rha ha.mera psychosis nh hua.moderate
level tha abhi

Hallucinations:

Do you seen voices that others cannot seen or seen faces that othes cannot seen?

Jb ma ice leta that b mje aese awazain ati thi,ur mahsos huta tha ka koi mera mobile hack
kr rha ha yapolice mere piche ha.lkn wo itni intense scenario nh huta tha.abhi
hallucination ka moderate level tha.

Orientation:

Orientation (Time):

todays date?

Aj 16 date ha

which month?

Ya february ka month ha

Orientation (Place)

Ya aik rehab center ha.

Orientation (Person):

whats your name?

Mera nam Daniyal ha.

Memory:

Remote memory:

where you were born?

Ma multan ma peda hua.

Recent Past Memory:

what you seen on tv last time

Tik tok (Bol channel)

Repeat words, glass, chair, table?

Client repeated the exact word accurately
General information/intelligence:
General knowledge questions
2+5=
7 (answered correctly)
Insight:
can you tell me about the nature of your disease?
Ma aik chronic bemari ma hun.jo mere sath sare zindagi rhe gi. ma apni whole
life ma recovery ma rh skta hun agr ma apni bemari ko understand krlun ur
manage krna sikh lun, q ka mri recovery 70% counseling pa ha. phly mere
counseling nh hui thi jiss ki waja se relapse hu gia.ab counseling mje relapse se
bachne ma madgar hu gi.

2-Formal assessment
Formal assessment include diagnostic test ant personality test.

Formal assessment Carried out through

 Drug abuse screening test(DAST)
 Mini mental state examination(MMSE)
 SMAST(short michighan alcohol screening test)
 Hospital anxiety and depression test(HADS)
 Beck anxiety inventory
 Anger scale

 DAST-
DAST consing of questions about patients drug use during the past 12
months.it includes 28 questions which had yes or no options which indicated
for making yes score (1)
Or no score 0.

Quantitative analysis of DAST-

Total number ofitems-28

Number of yes responses-253
Number of no responses-

Qualitative analysis of DAST-

Over 12 is definitely a substance abuse problems.and client scored 15 yes

responses which clearly means substance abuse.

 Mini-mental status examination(MMSE)

Mmse is a30 point questionnaire that is used extensively in clinical and
research settings to measure cognitive impairment.it is also used to measure the
severity of cognitive impairment and to follow the course of cognitive changes
in an individual over time,thus making it an effective way to document an
individuals response to treatment.
The client scored 24-30 which indicate no cognitive impairment.
 HADS
HADS is a 14 item measure designed to assess anxiey and depression
symptoms in medical patients,with emphasis on reducing the impact oof
physical illness on the total score.depression items focus on anhedonic
symptoms of depression.items are rated on 4-point severity scale.thus HADS
produces two scale one for (HADS -A), and one for (HADS-D),differentiating
the two state.

Quantitative analysis of HADS

Total no of items-14
Anxiety items-05
Depression items-09

Qualitative analysis of HADS-

Zigmond and snaith created this outcome measure specifically to avoid reliance
on aspects of common somatic symptoms of illness,like fatigue,insomnia and
hypersomnia.a tool was created for the detection of anxiety and depression in
people with physical health problems.Anxiety scoring is 13,which shows
clinical caseness. while depression is 11.Client is more closed to anxiety
symptoms.

SMAST (short michigan Alcohol screening test)

SMAST is a 13-item questionnaire.developed for Alcoholism screening
test. SMAST score 4 0r more shows potential Alcohol abuse reported.a full
assessment is required.

 Beck anxiety inventory-

This is 21 item questionnaire to measure level of anxiety.scoring from 8-15 is
mild,16-25 is moderate,26-63 is severe.client reported moderate anxiety.

 Penn state worry questionnaire-

Total items is 15.16-39 scoring shows low worry.40-59 shows moderate worry.60-
80 shows high worry.client reported moderate worry.

Diagnosis:

Moderate 300.02(F41.1), SUD and anxiety disorder.

Prognosis-

Recovery-

Recovery is satisfactory.in the first 2 months he sleep all the time, and physically and
mentally disturb or quite does not participate in activities. but as the recovery period
progressed he start taking group therapy or individual session. start sharing his experience
in group session. now in the 3 rd month of recovery, he start accepting addiction as chronic
illness, understanding the mechanism of addiction. taking 1 cigarette and loss of control
that lead to the vicious cycle of drugs, now insight has developed to manage it by focusing
on his emotions that disturbed him. Craving, shifting of thoughts(working on lessening the
future apprehensions on working the 1 step of recovery, (12-step of recovery),or learning
to come to follow ups in the initial start of emotional relapse.

Management and treatment-

Psychotherapy-

I recommend the CBT to client. I applied CBT on client to help him to find connection
between his thoughts, feelings or action. and increase awareness how they impact his
recovery. I helped him to identify negative automatic thoughts, by clearing his
misconceptions about addiction and his future apprehensions or fears. I helped him to
manage craving that he faced in early weeks of recovery. I helped to understand the
triggers that provoke him towards substances.

Management through CBT-

CBT interventions that applied on client to help him to manage the cravings ,thoughts or
emotions.
1-
Self- monitoring (gauging emotions or thoughts)

2-
Self-diagnose-
Helped him to diagnose you own problem, disturbing thoughts or emotions. your
own manager of life.to cope with stressful situation.

 Relaxation training. Apply progressive muscle relaxation technique.

 Calming technique
 My thought diary
CBT intervention for skills training that applied on client
 Problem solving worksheet.
 Weekly activity schedule.
 Self management plan worksheet.
 Monitoring early warning sign worksheet.
 Increasing motivation for psychological treatment.

12-steps of recovery model which emphasize on acceptance and spirituality.

Follow up Plans 
 In follow up plan continue same treatment.enhancing on learning the CBT
technique.
 New orders(ordering new medication according to the condition of patient)
 Referral
 Discharge plan
On follow ups implementation on recovery plan.

Addiction Recovery Plan

2- Working on Personal triggers.

2-Ways I can practice self-care.

3coping skills I want to learn to manage anxiety

4-Relapse prevention strategies I can practice:

 1.When I feel the urge to use or experience a craving, I will call my counselor
 2.I will attend meetings at a 12-step program every week (I won’t miss these
meetings)
Suggestion and recommendation-
There was some barriers supporting a less favorable environment for the client as
less professional and individual care and treating them in same way.family situation
is also hurdle that need to be sort out by hospital follow ups to create more care to
the client.there was not a suitable management plan for client to done with specific
things.
Case formulation-

Case formulation-
Client is 19 years old boy. since his childhood he does not seen any issue between
their parents. he had seen a peaceful environment. client belongs to a wealthy family
or elite class. he had contact with bad company or conduct parties or join clubs. talk
in very rapid way, irritability or restlessness shown form his actions. client was
feeling worry about future life. his sleep and appetite was also decreased. due to
anxiety he does not properly concentrate on his work.
1-
The use of illicit psychoactive substances is not a minority activity among young
people in the UK.results from the most recent British crime survey show that
some 50% o
f young people between the ages of 16-24 years have used an illicit drug on at
least one occasion in their lives(lifetime prevalence).(Ramsay and
Partridge.1999).
2-
Psychoactive substances use continues to be a global problem.a survey done by
United nations office on drugs and crime(UNODC) found that in 2014,247
million people between ages 15-65used illicit drugs at least once in previous
years.
Summary of case formulation-
Predisposing factors include Bad company,anxious personality.Precipitating
factors include bad company Effects of drug abuse and Fear of loss of social
circle.Maintaining factors Bad company Absence of awareness about
addiction in family.Protective factors are Parental care Right company
Rehabilitation suitable environment.
Appendix-