Department of Clinical Psychology; Faculty of Behavioral Health Sciences
PERSONAL INFORMATION
Name: XYZ
Father’s name: Ramesh
Age: 47
Gender: Male
Religion: Hindu
Marital Status: Married
Income: Not Known
Socio economic status : Average
Educa/tional qualification: Graduate
Address: Not known
Occupation: Business
Referred by: Friend
Reason of Referral: Counselling for quitting alcohol
INFORMANT-
Informant’s name: SM
Age: 43
Education: Graduate
Relationship: Wife
Time living & spent with the client : 22 years
Reliability and Adequacy of the Information: Reliable and Adequate
CHIEF COMPLAINTS:
• Inability to control drinking (8 YEARS)
• Suspicious behaviour (6 YEARS)
• Disturbed sleep (1 YEAR)
• Abusive Assaultive behaviour (1 YEAR)
• Odd behaviour (1 YEAR)
• Decreased Interaction (6 MONTHS)
ONSET: Incidious
COURSE: Progressive
PROGRESS: Detoriating
TOTAL DURATION OF ILLNESS: 08 years
PREDISPOSING FACTOR: Peer Group
PRECIPITATING FACTOR: Peer Group
PERPETUATING FACTOR: Confilcts with wife
HISTORY OF PRESENT ILLNESS:
• Patient was apparently asymptomatic about 08 years back when he first started remaining
fearful for his life and for his family member.
• Sometime we find him suspicious. the couple didn’t like Each Other much after getting
married which cause them to have a miserable life and
• He started addicted to alcohol and the situation didn’t go well even after getting two
children
• He rejects his food when offered by his family members & throws it on ground , through
he picks the same food later on himself and eat it. .
• He abuses people. For last 3 years he has become more aggresive and sometimes even
beats up his wife and children. He has now stopped talking to people
• The client is not able to sleep well . over the course of 1 year the patients sleep disturbed
significantly and it decreased to 3-4 hrs in night which used to be aroud 7-8 hrs
previously.
BEHAIOURAL OBSERVATION
Client was dressed well and looked good. he was obese, I eyes were red and hands were little
trembling. his voice was low and shaking. his tongue was slipping during the discussion. his eye
contact was not good. he loves his children. He is quite and polite with a normal tone and
daytime. sometime we find him suspicious. the couple didn’t like Each Other much after getting
married which cause them to have a miserable life and he started addicted to alcohol and the
situation didn’t go well even after getting two children
NEGATIVE HISTORY:
No history suggestive of:
• Choking sensation, impending doom, tremors, dizziness
• Preoccupation with specific body part/appearance
• Elated mood/racing thoughts/increased goal directed activity/increased religiosity/over-
grooming
• Fear of specific situation/places/objects/animals/insects
• Suspicion/hearing voices/wandering aimlessly/disorganized behaviour/posturing
• Crying spells/suicidal thoughts/remaining aloof
• Head injury/brain fever
Personal history: Could not be elicited
TREATMENT HISTORY:
Past history of medical illness / treatment: Not present
Past history of psychiatrist illness / treatment : Not present
FAMILY HISTORY:
• Patient is a middle child among 3 sibling
• Relationship with family members are cordial
• Due to aggressive behaviour, relationship with wife was not cordial
FAMILY GENOGRAM:
PERSONAL HISTORY-
1. Birth History: Detailed information could not be elicited.
2. Early Developmental History: Not available
3. Childhood History: Not available
4. Scholastic and extracurricular activities (Age, type of school, performance, regularity, peer
relationships, interest present status and reason to stopped education (if so): Not available
5. College history (Particular adolescent emotional or physical problem): Not available
6. Occupational history: Patient is a bussiness man. he is satisfied with his job.
7. Menstrual history: Not applicable
8. Sexual and Marital history (marital history, sexual issues, attitude towards pregnancy, sexual practices
including paraphilia/ sadism etc.): Could not be elicited
9. Religious History: Not available
10. Legal History: Not available
PREMORBID PERSONALITY-
a) Social relations:
Before the illness, patient social relationship was adequate.
b) Intellectual activities, hobbies and use of leisure time:
Patient loves to read books and play football
c) Predominant mood:
sociable, happy
d) Character (attitude to self, work and responsibility, interpersonal relationships, standards in moral,
religious and health matters, energy):
Interpersonal Relationships was Good. Attitude to Self and Others was very optimistic
PSYCHOMETRIC ASSESMENT
The Alcohol Use Disorder Identification Test (AUDIT) is used. To access alcohol consumption,
drinking behaviour and alcohol related problems.
RESULTS OF PSYCHOMETRIC ASSESSMENT
The result is 32 that means High-risk, Definite harm, also likely to be alcohol dependent.
PLAN OF ACTION-(ASSESSMENT & MANAGMENT)
SEASON 1:-
• Psychoeduate the patient
• for most of patient the transtaion is 90 days by that time craving and irrability will have
diminished considerable
SEASON 2:-
Based on client’s current schedule, activity scheduling was done
• reading read atleast 2 pages of any book.
• maintain a daily diary whuch you keep record of your day.
• at the end of the day before going to bed give youself 30 mins to reflect on your day.
• make a list of why to of why not.
• Not using phone after 9:30 at night and heading to sleep at 10:00 no matter sleepy or not,
preferably with the lights off or dimmed.
SEASON 3:-
• Start saving your money which you spend on liquid and spend upon your hobbies
• keep giving yourself short term goal
• understand the value of your hard earn money
• remove your condition of alcohol through replacing with the pleasurable objects.
• read more and more articles books and blog about benefits of living healthy life .
• join Alcohol anonymous group.
• eating the dinner by 9 preferable with family
• joining the yoga classes with wife
RECOMMADATION
• CBT.
• Strictly following tha schedule.
• realising the repercussion of not following the treatment.
• Alcohol anonymous group.
• Family counselling.
• Strictly follow the psychiatry medication STRICTLY.
SIGNATURE
