CHILD PSYCHODIAGNOSTIC REPORT

Supervisor: Ms. Maria Tanvir

Submitted by :

Nimra Tariq

25260

Laraib Nisar Kayani

23861

Mahnoor Naheed 23873

Faculty Of Science And Humanities

\Depoartment of Applied

Psychology

Academic year-Spring 2022

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RIPHAH INTERNATIONAL UNIVERSITY (GULBERG GREENS CAMPUS)

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 Declarati

I, Ms. nimra,laraib, mahnoor, do hereby solemnly declare that the work

submitted in this report is my own and has not been presented previously to

any other institution. The work has been carried out and completed at the

Department of Applied Psychology of Riphah International University,

Gulberg Green Campus.

Student’s Signature

Supervisor’s Signature

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Forwarding

The Clinical reports of us have been accepted in partial fulfillment of requirement

of the degree of Bachelors in Applied Psychology and are forwarded for further

necessary actions.

Supervisor

Ms. Maria Tanvir

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Approval

The Clinical reports of us have been accepted in partial fulfillment of

requirement of the degree of bachelors in Applied Psychology (MSCP).

Supervisor Ms. Maria Tanvir

Head of department Dr. Rabia Hanif

Dated:

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 Acknowledgement

In the name of Allah, the Most Merciful, the Most Compassionate, all

praise to be for Allah, the Lords of the worlds and prayers to Prophet Muhammad

(PBUH).

I want to start by expressing my gratitude to Ma'am Maria Tanvir, my

supervisor, whose knowledge was crucial in completing the report. The

positive criticism I received from her helped improve my ideas, which raised

the caliber of my work.

Additionally, I want to convey my sincere gratitude to my family

members, who have continuously provided me with support and

encouragement. Without their understanding, I would not have been able

to continue pursuing higher education.

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 Table of Contents

Case report # 1 3

Case summary

Bio Data…………………………………………………………………………………………..

Reason Refferal…………………………………………………………………………………..

Background

Family history…………………………………………………………………………………….

Personal History………………………………………………………………………………….

Recommendations……………………………………………………………………………… \\

References……………………………………………………………………………………..

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 CASE 1

DRUG CASE

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 Summary of Case

The client was male of 33 years old with the symptoms of substance use disorder. Client had active

psychological and social triggers in the environment which play role in relapse. Client had emotional

breakdown, low mood, crying spells and feelings of unworthy personality further, probing identifies no

self-harm or suicidal tendencies. a tentative diagnosis of “Opioid use Disorder (OUD)” is given to the client.

The client face problem in change in nature, intensity, and/orfrequency of problems overtime, prodromal

manifestations, others past problems of a psychological nature, no. of attacks. He face problems of The

inability to control opioid use, Uncontrollable cravings, Drowsiness,Changes in sleep habits, Lack of

hygiene,Isolation from family or friends, and frustation.

Demographic Information

Name: xyz

Age: 33

Gender: Male

Occupation Banker

Mother: Alive

Marital Status: married

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 Religion: Islam

Siblings: 6

SES: Middle class

Family structure: Nuclear family

Informant: wife

Reasons and Source of Referral

He came with problems of the inability to control opioid use,

Uncontrollable cravings, Drowsiness,Changes in sleep habits, Lack of

hygiene,Isolation from family or friends, and frustation.,

Presenting Problems:

‫ سال ہو گیاہے ۔ جب مجھے نشہ نہیں ملتا میں چڑچڑاپن ظاہر کرتا ہوں ۔ٹینشن کی وجہ سے نشہ‬1 .5 ‫مجھے نشہ کرتے‬
‫شروع کیا۔میں نے بہت کوشش کی کے میں نشہ چھوڑ دوں لیکن میں نہیں چھوڑ سکا ۔ میں نے دیکھا کے یہ نشہ تو میرے لیے‬
‫ہی بنا ہے اور چھوڑنا مشکل ہو گیا ۔‬

History of Present Illness

The onset of the problem was 1.5 years ago. When one of the client’s friend brought heroine to him for

weighing it. At that time client was unaware of that drug and out of curiosity when he asked him about

that drug his friend ask him to sniff and gradually the client become addicted to it. (most recent physical

exam: date and results; current medications; health condition since childhood including details of serious

illnesses/disabilities suffered and surgery undergone; eating and sleeping habits if remarkable and any

change of same)

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When and what duration treatment undergone:
He is not on any medications and has not taken any medication in the past related to any problem.
Name of drug:
Heroin
Dosage of drug:
1.5 grams
Response to treatment:

As no prior treatment was conducted so it had no impact on clients health.

Medical history:
He is not on any medications and has not taken any medication in the past related to any problem.
Health conditions since childhood:
Client always had good health since childhood. He has no previous history of any illness, disability or even
surgery.
Eating and sleeping habits:
These habits are normal.

Birth and early childhood:

The client lives in Islamabad and belongs to an upper middle class family. He lives in a joint family system.

The client was 2nd born child of the Family.

Family History

(migrations, marriages, serious illnesses, deaths, jobs of earningmembers, relationship with family
members)

The client was born and raised in Islamabad, he never migrated.

Serious illness:

There is neither history of serious psychological illness nor any history of drug abuse in family.

Deaths:

The client has experienced no significant deaths of closed ones.

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 Jobs of earning members:

The client lives in a joint family this plays role in joint family business.

Relationship with family members:

He had a very good relationship with his parents and siblings. The client is married and his relationship
with his wife is not good. She force him to stay away from bad influence.

(a) Family psychiatry history:

No prior traces of any psychology illness are found in client's family.

(b) Family medical history:

The family has no significant history of genetic medical disorder (the one running in genes)

(c) Family relationship:

 Client relationship with family:

Overall good terms with all the family members except wife.

 Family relationship with client:

The siblings and parents share a really good bond with the client but client
doesn’t have a good relation with wife .

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Marital History (occupation of husband wife, age of husband wife, duration of married
life, relationship among husband wife, conflicts)

Spouse none no. of child

 relatiionship with spouse:

________ Not good due to recurrent arguments

 Spouse relationship with client:

___ The spouse forbade client from bad influence, due to which client doesn't shares
good relationship with his wife. She also forbade him to meet his
friends._____________________________________________________________
_________________________
 Expectations from spouse:

The client expects his wife to let him meet his friends. He doesn't want him to
forbade him taking heroine

Unmarried:

 Single_ _

 Engaged

(Married)

 Relationships_ _ _

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 Work history:

Client relationship with colleagues:

The client shares good relationship with his colleagues because they're mostly his family members .

Colleagues relationship with client:

The colleagues too share a friendly relationship with client.

No. of jobs changed: No history of changed in jobs

 Reasons: No

Educational history:

 No. of school changed: No schools changed.

 Reasons:

 School name: Sls Montessori and high school larazar campus

 Client relationship with peers Good relationship with peers and friends.

 Peers relationship with client Fine relationship with teachers.

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  Client relationship with teachers Teachers treated client appropriately.

 Teachers relationship with client Good relationship.

Social history (Neighbors, friends, relatives and overall):

The client had few friends with whom he spends most of his time. He had a good relationship with
them. Client report no premarital or extra marital relationship. He has good and healthy relationship
with neighbors, relatives and friends overall.

Orientation (person, place, time)

His orientation was good as he responded accurately when asked about the place, season, year, date,
month, time and city.

Sleep (insomnia, nightmares, sleep walking)

The client significantly faced no sleeping difficulties. He had no symptoms of insomnia, nightmares
and sleep walking.

Attention (concentration , memory)

Client’s attention and concentration was proper as he performed correctly in digit span and
calculations. His memory, intellect and vocabulary were good. He was able to recall the event from in
past easily. His information and vocabulary was proper as he correctly stated the name of president of
Pakistan, prime minister and the capital city. He was good in abstractions too as he clearly stated the
difference between two objects.

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 Perception (hallucination, auditory, visual, tactile, somatic, olfactory)

No delusions and hallucination were present or reported by the client.

Thoughts (usual content including suspiciousness and delusions, conceptual disorganization

including loosening of association)
The client had quite vivid thoughts and knew how to communicate his thoughts. He had no signs of
delusions and conceptual disorganization.

Affect (crying spells, depression, guilt feelings, suicidal excitement, hostility, grandiosity,

The client was dysphoric and effect was according to mood and thought patterns. He
sometimes had crying spells and blunted affect.unted affect)

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 Clinical Interview

The client behaved quite well during the interview. His rate of speech was slow and he was stuttering as well
but tone was soft. The quality of speech was emotional moreover clarity was observed in content of speech.

Behavior Observation

(speech: mute, talkative, abusive, motor restless, assaultive, destructive, excited motor retardation)
No unusual behavior or movement was observed. The client was very cooperative and was not defensive at
all. The client was poor in maintaining eye contact and was looking down most of the time.

Mannerisms and posturing (unusual gestures, preservative movements)

The client was a well behaved individual His posture was appropriate. Client was well-groomed and well-
dressed with suitable weight according to his age.

Personality Traits: (Pre-Morbid)

The client had a very joyful personality before the induction of substance. He had life goals and wanted to
achieve them by hardwork.

Current: (Paranoid, schizoid, schizotypal, anti-social, borderline, histrionic, narcissistic, avoidant,

dependent, obsessive compulsive, passive aggressive)
Now he doesn't finds motivation to do anything. He's passively aggressive besides no appearance of any other
symptoms.

Tentative Diagnosis:
Opioid use disorder 304.00 (F11.21) severe, in early remission.

Recommendations (also list test):

Medication-assisted treatment (MAT)
Medication-assisted treatment (MAT) is an effective treatment for individuals with an opioid use disorder. It
involves use of medication along with counseling and behavioral therapies. Brain chemistry may contribute to
an individual's mental illness as well as to their treatment. For this reason medications might be prescribed to
help modify one's brain chemistry. Medications are also used to relieve cravings, relieve withdrawal symptoms

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and block the euphoric effects of opioids. MAT has been shown to help people stay in treatment, and to reduce
opioid use, opioid overdoses and risks associated with opioid use disorder.
Three FDA-approved medications are commonly used to treat opioid addiction:
Methadone – Prevents withdrawal symptoms and reduces cravings in people addicted to opioids. It does not
cause a euphoric feeling once patients become tolerant to its effects. It is available only in specially regulated
clinics.
Buprenorphine – Blocks the effects of other opioids, reduces or eliminates withdrawal symptoms and reduces
cravings. Buprenorphine treatment (detoxification or maintenance) is provided by specially trained and
qualified physicians, nurse practitioners and physician assistants (having received a waiver from the Drug
Enforcement Administration) in office-based settings.
Naltrexone – Blocks the effects of other opioids preventing the feeling of euphoria. It is available from office-
based providers in pill form or monthly injection.
Cognitive behavioral therapy CBT:
CBT is often an important part of treatment and is especially beneficial for people who are also struggling with
chronic pain or psychological disorders (such as depression or anxiety). CBT for substance use disorders can
be delivered in a group or individual format. Some of the strategies used in CBT for substance use disorders
include:
providing education about substance use disorders and the effects of drugs on the body and brain;
working with people and their families to identify alternatives to drug use;
reducing exposure to “high risk” situations for drug use;
providing incentives, or rewards, for abstaining from drugs;
teaching individuals how to identify the “triggers” that create craving and urges to use drugs;
training in skills to help manage triggers, like problem-solving and coping skills;
increasing structure and valued activities;
providing tools for thinking in more helpful ways when experiencing urges to use drugs; and
Providing general strategies for coping with difficult situations.

Because chronic pain is highly common in people with opioid use disorder, CBT can also be useful for helping
people to manage their pain. CBT can also be used to help with psychological symptoms and disorders, such as
anxiety and depression, which are also common in people with opioid use disorder. People with opioid use
disorder can also benefit from engagement of family or other important people in their treatment and the use of
mutual help or other recovery supports.
Psycho education:

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Psycho education is offered to people who live with a psychological disturbance. A goal is for the patient to
understand and be better able to deal with the presented illness. Also, the patient’s own strengths, resources and
coping skills are reinforced, in order to avoid relapse and contribute to their own health and wellness on a long-
term basis. Psycho education can be provided to the client to develop an insight in him about the problems
through which the client is going through and about the effectiveness of the management. Client should be
psycho educated regarding the effects of drugs that he had on his life, relationship and health. By using bio-
psycho-social model the client can be educated regarding the treatment, and the course of it. The client should
also be educated about the point which were in the favor of prognosis and points against it. The addiction cycle
can also be discussed with the client that how with time addict develops tolerance with the drug that leads
toward the increased dose and how the use changes into abuse, and the person become dependent on the drug
for his everything. The outcome of this technique is positive and the client develops proper insight about his
problem and how his problem progressed.

The road map technique:

The road map technique is used with addictive patients that provides with two paths for recovery. One path
defines person’s life in the influence of drug, while the other path with elimination of drug from life. This
technique can be used with the client as a recovery technique of relapse prevention. Client is provided with a
road map that had two alternate. One road manifested client’s life under the influence of drugs and the other
was the way without drug. The client is asked to let the incentives and punishment on both the ways, and select
his own path, on which he want to go, keeping in view all its perspectives. Client chose the path without drug
use that according to the client is the road that will make his future bright. The outcome of this technique is
positive, and the client is able to discriminate among two paths, and he chose the right path for him that will
make him close to his parents, and will make him free from the life of uncertainty.

Relapse prevention technique:

Relapse prevention approach is used with the client to develop coping skills to manage high risk situations, to
make life style change to decrease the need for drug, to prepare for interrupting lapses so that they do not lead
to relapse and to prepare the client for managing relapse so that potential harms may be minimized. In relapse
prevention technique the client is asked to explore the situations, events and triggers that may have led to
relapse in the past. In it client is also encouraged to avoid the situations and events that can cause the relapse.
Goal setting is also done at this step, in which the client is asked to set goals of him that will make him

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enthusiastic, and to keep him away from relapse. The outcome of the technique is positive. The client is fully
aware about his problem, and by goal setting and trigger identification he also became aware to prevent relapse

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