The client S.

A was 30 years old he was suffering from substance abuse disorder he came with legs &
arms pain, diarrhea, nosiness & anger symptoms. & he faced that problem denial 2 years. Assessment
was done by mental status examination (MSE), Clinical Interview the result concluded that he was
suffering from Substance Abuse Disorder (481) on the basis of presenting complaints and physical
condition and history explained by her parents

Case No: 05

Bio Data

Name:

M.S

Age:

30 Years
Gender:

Male

Education:

Metric

Birth Order:

Last one

Occupation:

Auto mechanic

Marital Status:

married

No of siblings:

4 bro, 4 sis

Socio- Economic status :

Middle class

No of children

2
Source of referral:

Father

Reason for referral:

The client was referred by psychiatric unit for the assessment and management purpose due to some
problem like pain in legs, diarrhea, and anger last 2 years.

Presenting complaints

Duration Presenting complaints

1-‫۔ٹانگوں اور ہاتھوں میں درد۔‬ ‫سال‬2

2- ‫سال‬2 ‫۔کیپسول کے استعمال کے بعد دماغ کام کرنا چھوڑ دیتا تھا۔‬
‫ ڈائیریا اور چکر آتے تھے۔‬،‫۔متلی‬3 ‫سال‬2

4‫۔غصہ آتا تھا‬ ‫سال‬1

5-‫۔بیوی اور بچوں سے مار پیٹ کرتا تھا‬ ‫سال‬1

History of presenting illness

The client came with his bad habit of using drugs, he was used the large amount of drugs and used the
different type of drugs like hash, crystal powder, alcohol and other type of drugs. But the reason of
starting the drug was a client girlfriend. When the client’s girlfriend left him then he became mentally
disturbed, then he was started taking the drugs. He started using the drug before his marriage his family
members was also very worry about his bad habit of drugs but client say that he can’t live without drugs
when he was uses drugs he will be in happy mood client wife was also worry because her husband
behavior was very aggrieves with her and some time he will be physical fight with her

Past psychological history

There was no psychological history of client or his family members

Past medical /surgical history

There was no past medical or surgical history of client

Family history

Client relation with his wife was not satisfied mostly the client was abusing his wife and left his family.
The client did the entire act because of her girlfriend, and started using drugs. He loved her very much
but she was left him. Asked him to get married but he was not happy with his wife. The client father
expired 1 year ago, and his mother also expired 6 months ago. The relationships with his parents were
good. He was living separately from his siblings

Personal history

He was not confused during his bodily changing. He remembered old those days in which he played with
his siblings.

A incident happen, when his girlfriend left him alone and went to abroad, he felt being alone and
mentally disturbed, he felt that a women deceived her so that why he using drugs through his friends
but his family was not supportive with him

Drugs History

The drugs history of client was also was alarming

Client use some different types of drugs like alcohol crystal powered cocaine

Client use alcohol form last 2 years and crystal powder and cocaine was use last one year in huge
amount and also simple cigarette use daily

Forensic history

Client was having a forensic history in which his childhood he was took a treatment of his chopped hand.

Psychosexual history

The client spent a time with his girlfriend He had a psychical relation with his girlfriend. The sexual life
with his wife was not satisfied but when used drugs then he forced his wife

Behavioral Observation

His appearance and behavior was appropriate. When he entered in the room he was not the withdrawal
form. His sitting style was very relax and comfortable. But sometime he showed restlessness. He wore
the light color dress. He provided information about his present was objective. His facial expressions
have shown the problem with him. His sitting pasture was not proper. He was sitting on the edge of the
chair. He maintained good eye contact.

Case formulation
A 30 year old client came with the symptoms of substance abuse disorder therapist take all necessary
information of the client like personal information family and work related and further assess the
problems of client through mental state examination(MSE) and give the Psychotherapy like Behavior
therapy, Counseling and Medication to resolve client problems and there is 45% chances of the client or
recover his problems

Assessment plan

In assessment plan which include formal and informal techniques

Informal assessment which include clinical interview and behavior observation and formal assessment
include

Mental State of Examination (MSE)

Diagnosis

According to DSM-5client was suffer in Substance Abuse Disorder (481)

Treatment plan

Although there’s no cure of a substance abuse of drug addiction treatment option explained blow can
help to overcome an addiction and stay drugs-free treatment depend on the drug used and any related
medical or mental health disorders have long term follow up is important to prevent elapse

Chemical dependence treatment

Individual group or family therapy sessions

A focus on understanding that nature of addiction becoming drug free and preventing relapse

Motivational enhancing therapy

Family therapy

Community reinforcement approach

Detoxification

The goal of detoxification also called Detox or withdrawal therapy is to enable you to stop taking the
addiction drugs as quickly and safely as possible and it can only possible in drugs addiction center or
hospitals

Withdrawal from different categories of drugs such as depressants stimulants or opioids-produces detox
may involve to reduce the dose of drugs or temporarily substituting other substance

Behavior therapy technique

Behavior therapy is a part of treatment of drug and types of psychotherapy psychologist are help you to
stop drugs taking through counseling

Help you to develop ways to cope with your drug craving and suggest strategies to avoid drugs and
prevent relapse

Talk about issues regarding client job legal problems and relationship with family and friend

Drug addiction cures able?

Addiction treatment must help the person do the following

Stop using drugs

Stay drug free

Session Report

Therapist done only 2 session with client

1st session

in his first session talk about his problems and take an clinical interview and behavioral observation
first session was 45 mints

2nd session

and second session was 50 mints in 2nd session talk about his personal and family history in detail and
make a treatment plan for him like Behavioral counseling Medication, Long-term follow up