CLINICAL REPORTS
Submitted By:
Qamar ul Islam
University Roll No. BPSF15M011
B.S Psychology
Session 2015 – 2019
Submitted to:
Mam shumaila Ishaq
Department Of Psychology
University of Sargodha (Gujranwala Campus)
In partial fulfillment of requirement of the degree of Bachelors of Science in
Psychology
Department of Psychology
University of Sargodha (Gujranwala Campus)
I certified that the candidate, Mr. Qamar ul Islam, University roll# BPSF15M011 has
conducted the case report under the supervision of Miss Shumaila Ishaq. He has prepared the
case reports according to the norms of University of Sargodha.
Head of Department
Dated:
Supervisor
Acknowledgements
I would like to thank the supervisor, head of department mam Shumaila Ishaq, institutes
which permit me to write case report and also the clients who permit me to talk with them.
Qamar ul Islam
Table of content
Serial no.
Case no
1
Case 1
2
Case 2
3
Case 3
4
Case 4
Case report-1
Bio data
Name: R.Z
Age: 20 years old
Gender: Male
Education: Matric
Number of siblings: 3 siblings, 2 brothers and one youngest sister
Birth order: Eldest
Occupation: Nil
Socio-economic status: Moderate
Marital Status: Un-married
Informant: Client himself
Source of referral: Referred by client’s father
Place of referral: Mian Afzal Trust Hospital (MATH)
Reason for referral: Client was referred in Mian Afzal Trust Hospital because client has a
habit of using drugs.
Presenting complaints
History of past illness
The client had been taking drugs nearly from 5 years. He was admitted in fountain
house because of drug addiction. But his addiction was strong. He was not able to quit
addiction of drugs. He discharged from the hospital on the responsibility of his parents. But
he never quit his habit of drug addiction.
History of present illness
Client was 20 years old young boy. He came to the hospital with the complaint of
drug addiction. He has the habit of drug addiction for 5 years. He was addicted to multiple
drugs e.g. heroine, ICE and alcohol (occasionally) etc. Client had a love relationship with a
girl. They broke up due to some reason which made the habit of addiction more strong. Break
up boost up the addiction of drugs. He did not report any other psychotic problem. He was
admitted to fountain house before coming to Mian Afzal Trust Hospital. His habit becomes
stronger than before so his father admitted him in the Mian Afzal Trust Hospital for his
betterment. Client’s current condition is not much better than before.
Family history
Client’s father was an officer. He belonged to family of moderate socio economic
status. His father had 2 wives. They all live together. Client step mother has no child. Client
had good relations with his family members except his brother. He lacked the feeling of
acceptance from his brother. His father supported him financially. His mother came to meet
him in the hospital mostly. He was more attached to his mother. He had loving relation with
his sister.
Educational history
Client did go to school. He was matric pass. He quit his study in I.com.
Personal history
Client was the eldest of all his siblings. He was 20 years old. He was sent to his aunt’s
home without his will. His father enforced him to go to his aunt’s home. He left his home
when he was in grade 3. He was not comfortable and happy in his aunt’s home.
Occupational history
He worked online for small duration than he shifted to Lahore.
Assessment tools
The assessment tools used in the case report were mental status examination and Beck
Anxiety Inventory.
Mental status examination report
Mental status examination was used to assess the mental state and behavior of client.
In appearance client was good in hygiene. He was comfortable during conversation. He was
confident and had good flow of speech. He was good a decision making and orientation. He
had insight of his problem.
Beck Anxiety Inventory
Beck anxiety inventory was used to evaluate anxiety of client as the client reported to
be anxious at some time during day.
Quantitative analysis
Raw score
Range
Category
8
0-21
Low anxiety
Qualitative analysis
Beck anxiety inventory was used to measure the anxiety of client. The raw score was
8. It indicates low level of anxiety which does not seem to be problematic.
Case formulation
The client was a 20 years old young boy. He came with the principle complaint of
drug addiction. His habit of drug addiction was very strong.
The client considered his family supportive. He has good relation with his family
except his brother. He felt worthless in front of his brother. He had a love relation but they
broke up which enhance clients drug habit. Client left his home when he was in grade 3 and
went to his aunt’s home without his will. He felt lonely sometime at his aunt’s home. He was
not comfortable. He has no other psychotic problems. However client reported complain of
feeling anxious at some time of day so Beck anxiety inventory was used to assess anxiety. He
scored 8 points in this test which indicates low anxiety, so it is not problematic. Mental status
examination indicates that client had good recovery of his problem. He had low degree of
anxiety.
Tentative diagnosis
Mild anxiety and drug addiction
Treatment plan
Relaxation therapies will be used for treatment. Drug treatment can include behavioral
therapy (such as cognitive-behavioral therapy or contingency management), medications, or
their combination. Behavioral therapies can help motivate people to participate in drug
treatment, offer strategies for coping with drug cravings, teach ways to avoid drugs and
prevent relapse, and help individuals deal with relapse if it occurs. Behavioral therapies can
also help people improve communication, relationship, and parenting skills, as well as family
dynamics.
Prognosis
It might take 3 to 4 months for the treatment of drug addiction.
Case report-2
Bio data
Name
S.A
Age
23 years
Gender
Male
Education
Matric
Socio-economic status
Moderate
Number of siblings
6 siblings, 3 brothers and 3 sisters
Order of birth
third
Marital status
Unmarried
Informant
Client himself
Source of referral
Client’s father
Place of referral
Mian Afzal Trust Hospital
Reason for referral
Client was referred in Mian Afzal Trust Hospital because client
had a habit of using drugs. He felt sad and anxious.
Presenting complaints
Symptoms
Following was the symptoms:
Recklessness
Anxiety
Sadness
Irritated
Drug addiction
Restless
History of present illness
Client was 23 years old man. He came for treatment to hospital with the complaints of
sadness, tension and drug addiction. He was addicted to ICE, heroine and alcohol. He started
to take drugs when he was about 13 or 14 years old. Once he had fight with his elder brother
and in anger he went to his friend. His friend offered him to drink alcohol. From that time he
started to take drugs. Because of taking drugs he felt sad and anxious most of the time. The
client’s father bought him to Mian Afzal Trust Hospital for treatment, Gujranwala. He was
better than before but still he felt sad and anxious.
Family history
Client belonged to a moderate class family. According to client his father was loving
and supportive. His father was a railway employer with 60,000 pay. Client’s mother was a
house wife. Client was more attached to his mother. His mother loved him more than his
father. Client was 6 siblings. Client had good relation with his eldest sister but he was
considered good by his brother in law. Client’s elder brother talked rudely with him. Client’s
younger brother had average relation with him. Client’s younger sisters did not have
comfortable relation with him. Overall home environment was good.
Personal history
Client’s birth was normal. He was naughty in his childhood. His family had a lot of
complains from neighborhood because of his actions. He had no responsibility regarding his
home.
Educational history
He had gone to school. He had bad relation with his teachers. He was not hard
working student. He was not so good in his studies.
Premorbid personality
Client was careless. He was good in his hygiene and well-maintained. He was
naughty and brat.
Assessment tools
The functioning of client was evaluated by using following assessment tools:

Mental status examination (MSE)

Beck depression inventory (BDI)

Beck anxiety inventory (BAI)
Mental status examination report
Mental status examination was used to assess the present mental state and behavior of
client. Client had dressing according to situation. He had poor hygiene, his hair and beard
was undone. His flow of speech was low. He sat on the edge of chair and was not
comfortable. He felt irritated. He had improper movements of hands and legs. He reported
himself sad and anxious. He did not have suicidal thoughts. He was feeling regret. He had
poor judgment and orientation. Client was aware of his problem.
Beck Depression Inventory report
Beck depression inventory was used to assess the depression level of client.
Quantitative analysis
Raw score
Range
Category
18
14-19
Mild
Qualitative analysis
Beck depression inventory was used to assess the present condition of client. The raw
score was 18. It indicates that client suffering from mild depression. This shows that the
client would not hurt himself and others because of his depression. But still it shows sadness
of client.
Beck Anxiety Inventory report
Beck anxiety inventory was used to evaluate the level to anxiety of client.
Quantitative analysis
Raw score
Range
Category
17
17-29
Moderate
Qualitative analysis
Beck anxiety inventory was used to evaluate the level of anxiety of client. Client
scored 17 points. This score indicated that can disturb client physically and mental well-
being. Client felt trembling in his hands. He felt sweating without any change in temperature.
He felt irritated. He felt aggressive. He was not sure and had no proper plans for his future.
Case formulation
The client was 23 years old, 3 in 6 siblings. Client came with complains of
depression, anxiety and drug addiction. The client faced problem nearly for 10 years.
The client considered his father as loving and supportive. Client mother loved him.
He had good relation with his eldest sister but he was considered good by his brother in law.
Client’s elder brother talked rudely with him. Client’s younger brother had average relation
with him. Client’s younger sisters did not have comfortable relation with him. Once he had a
fight with his eldest brother that made him to take alcohol after that other problems started
along with it.
The personality of client was assessed by using mental status examination (MSE),
beck depression inventory (BDI) and beck anxiety inventory (BAI). MSE revealed that client
was not able to maintain his hygiene. His mood was irritated and sad. He had poor orientation
and judgment. On BDI he scored 18 point which revealed mild depression. On BAI client
scored 17 points which revealed moderate anxiety.
Tentative Diagnosis
He was diagnosed mild depression and moderate anxiety.
Major depression may impair the inference of others’ feelings (J Affect Disord, 2005), but in
non-clinical subjects, mild levels of depression and anxiety may counter intuitively enhance
this ability (Cogn Emotion, 2005). The client also had mild level of depression and moderate
level of anxiety which may trigger other feelings.
Treatment plan
To treat depression effectively, treatment may include herbal remedies, CBT, or
lifestyle adjustments. It’s especially important to contact your doctor in cases of mild to
moderate depression, as the symptoms may not be noticeable to others. Though it may take
time for treatment to make a noticeable difference, reaching out to your doctor is the first step
toward feeling better. Antidepressants should not be prescribed for mild depression.
Cognitive-behavioral therapy (CBT) works to replace negative and unproductive thought
patterns with more realistic and useful ones. These treatments focus on taking specific steps
to overcome anxiety and depression. Treatment often involves facing one’s fears as part of
the pathway to recovery. Interpersonal therapy and problem-solving therapy are also
effective. Consider joining a support group and relaxation therapies. While behavior therapy
is a major component of cognitive behavior therapy (CBT), unlike CBT it doesn’t attempt to
change beliefs and attitudes. Instead it focuses on encouraging activities that are rewarding,
pleasant or give a sense of satisfaction, in an effort to reverse the patterns of avoidance and
worry that make anxiety worse. E-therapies, also known as online therapies or computeraided psychological therapy, can be just as effective as face-to-face services for people with
mild to moderate anxiety. Most e-therapies follow the same principles as CBT or behavior
therapy, and the structured nature of these treatments means they’re well suited to being
delivered online.
Prognosis
It might take 6-8 sessions over 10-12 weeks for the psychological treatment of mild
depression and moderate anxiety.
Case report-3
Bio data
Name
A.A
Age
25 years
Gender
Female
Education
B.A
Socio-economic status
Moderate
Number of siblings
5 brothers and 5 sisters
Order of birth
Middle child
Marital status
Divorced
Informant
Client herself
Source of referral
Client’s family
Place of referral
Civil hospital Gujranwala
Reason of referral
Client was referred to hospital because of her problems and
change in behavior after divorce.
Presenting complaints
Symptoms
Worthlessness
Restlessness
Irritation
Headache
Fatigue
Hopelessness
Weeping
Sadness
History of present illness
Client was 25 years old woman. She came to the hospital with the compliant of
weeping, hopelessness, fatigue, headache, irritation, sadness, restlessness and worthlessness.
Client came to the hospital after 11 months of her marriage. Client was married 11 months
ago. Client’s husband and in laws was not in good terms with her. They lied to client and her
family before marriage. Client’s husband doubted and blamed her without any reason. Her
husband divorced her after 19 days of her marriage. Client’s problem started after she got
divorced. Client’s family members noticed change in her behavior and referred her to hospital
for treatment.
Family history
Client had good relation with her father. Client had loving relation with her mother.
Client was 10 siblings, 5 brothers and 5 sisters. Client’s brother was disabled. Client was
middle child. Client was in good terms with her siblings. But she was not too close to share
her feelings and other things with her family members. Overall home environment was good.
Personal history
Client had normal birth. Client’s childhood was good. Client was satisfied with her
childhood.
Educational history
Client was educated woman. She got degree of B.A. She had healthy relation with her
teachers and fellows in school and college too.
Occupational history
Client had a job after she completed her education but she quit her job for marriage.
Marital history
Client got married with her permission. Client’s marriage happened in hurry within 8
days. Her marriage was not successful marriage. She did not have strong and good relation
with her husband. Her husband did not treat her well and doubted her without any reason. She
got divorced after 19 days of her marriage.
Premorbid personality
Client was active and fresh. She was happy. She was responsible for her duties.
Assessment tools
Assessment tools were used to assess the present condition of client. Following tools were
used:

Mental status examination (MSE)

Beck depression inventory (BDI)
Mental status examination report
Mental status examination was used to assess the current mental condition and
behavior of client. Client showed low flow of speech. She was taking pause while answering.
She was not sitting comfortably. She was sitting with her face down. She had hunched
posture of shoulder while sitting. She talked nervously and was not confident. She did not
maintain eye contact. She had tears in her eyes during conversation. She was not willing to
interact. Her mood was very sad. She was hopeless about her future. She was aware of her
problem.
Beck depression inventory report
Beck depression inventory was used to evaluate the depression level of client.
Quantitative analysis
Raw score
Range
Category
33
29-63
Severe
Qualitative analysis
Beck depression inventory was used to assess level of depression of client. Client
scored 33 point in test which indicates severe form of depression. This level of depression of
client can cause her physical harm and can also affect the mental well-being of client. This
result indicates that client was feeling worthless, irritated and sad. She was hopeless about her
future.
Case formulation
Client was 25 years old woman. She came with the compliant of weeping,
hopelessness, fatigue, headache, irritation, sadness, restlessness and worthlessness.
Client considered her father as good person and was in good terms with her father. Client had
a loving relation with her mother. Client was 10 siblings, 5 brothers and 5 sisters. She was the
middle child. Her brothers were disabled beings. She got married at the age of 24. She had
issues with her marital life. Her husband divorced her after 19 days of her marriage. Her
problem started after divorce. Mental status examination and beck depression inventory was
used to assess client behavior and mental status. She was sad and weeping during
conversation. She had insight of her problem. Beck depression inventory was used to assess
level of depression of client. Client scored 33 point in test which indicates severe form of
depression. This level of depression of client can cause her physical harm and can also affect
the mental well-being of client. This result indicates that client was feeling worthless,
irritated and sad. She was hopeless about her future. By considering all aspects client
condition falls in the criteria of depression.
Psychosocial and environmental stressors are known risk factors for depression.
According to Harris (1976), those who face long term difficulties (issues with marital life,
divorce) were more likely to appear to disturb. The client had faced the problem with
marriage life.
Tentative diagnosis
Depression
Treatment plan
To treat depression effectively, treatment may include herbal remedies, CBT, or
lifestyle adjustments.
Following are the techniques to relax the client of depression:
Deep breathing
Deep slow breathing can help the client to release anxiety and relax from head to toe.
Combine deep breath with meditation will be used for greater relaxation.
Exercise
This is a great relaxation technique and also offers a great physical health benefits.
Yoga is a specific beneficial therapy because it focuses on mediation, balance, deep breathing
and relaxation at the same time.
Scribble out stress
Therapist might assign home work to client like write a diary by giving some free
time to you and write about your fears.
Prognosis
It might take 9 to 10 sessions for treatment.
Case report-4
Bio data
Name
S
Age
36 years
Gender
Male
Education
Graduation
Socio-economic status
Low
Number of siblings
3 brothers and 2 sisters
Order of birth
1st
Marital status
Married
Number of children
1 daughter
Informant
Client himself
Place of referral
Civil hospital Gujranwala
Reason of referral
Client was referred to hospital for assessment and treatment.
Presenting complaints
Symptoms
Headache
Sadness
Guilt
Irritability
Fatigue
Sleep disturbance
Appetite problem
Drug addiction (sniffing)
History of present illness
Client was 36 years man. He came to hospital with the problem of headache, sadness,
guilt, irritability, fatigue, sleep disturbance, appetite problem and drug addiction (sniffing).
Financial issues of client were the initial of problem. Client had no experience in business but
due to poor health of client’s father he had to join the business. He had lost to face loss in
business which causes him trouble. He developed feelings of guilt. Client’s unwilling
marriage adds up to his problem. After marriage the symptoms became prominent. He started
sniffing as a factor of relief. Then it became addiction. Client came to the hospital for
treatment of his problem.
Family history
Client’s father was ill person. Client had good relation with client. Client’s mother
was house wife; client had loving relation with his mother. Client was 5 siblings, 3 brothers
and 2 sisters. Client was eldest of all. Client had decent relation with his siblings. Overall
home environment was nice.
Personal history
Client had average childhood. On client’s birth his family was very happy. As client
was eldest of all he had to take responsibility of his family.
Educational history
Client had decent educational background. He was in good terms with his fellows and
teachers.
Occupational history
After graduation he started business. He had no experience about how to run business.
He had loss in business. He ran out of business because of in-experience. He had to face lots
of trouble in his career life. He had financial issues in business too.
Marital history
He was married at the age of 33. He was unwilling for getting married. He had cousin
marriage. He was forcefully married to his cousin, his family pressurized him. He was not
happy and unsatisfied with his marriage. He had understanding issues with his wife. He was
about to divorce his wife. He had 1 daughter. Her daughter was 1.5 years old.
Premorbid personality
Client was not so responsible person. He was careless.
Assessment tools
Following assessment tools were used to assess the client’s current mental well-being and
behavior:

Mental status examination (MSE)

Beck depression inventory (BDI)
Mental status examination report
Mental status examination was used to assess the current mental condition and
behavior of client. He was wearing clothe according to weather and environment. Client took
pause while answering and speaking. He was not sitting properly and comfortably. He was
sitting with his face and shoulder down. He had regrets about past. He had poor eye contact.
He was sad. He had insight of his problem. He had poor decision making sense. He wanted to
get treated from his problem.
Beck depression inventory report
Beck depression inventory was used to evaluate the depression level of client.
Quantitative analysis
Raw score
Range
Category
23
20-28
Moderate
Qualitative analysis
Beck depression inventory was used to assess level of depression of client. Client
scored 23 point in test which indicates moderate level of depression. This level of depression
of client can cause him physical harm and can also affect the mental well-being of client.
The result showed that he was irritated. He had fatigue, sleep disturbance, guilt and poor
appetite.
Case formulation
Client was 36 years male. He came to hospital with the problem of headache, sadness,
guilt, irritability, fatigue, sleep disturbance, appetite problem and drug addiction (sniffing).
Client’s father was ill person. Client had good relation with client. Client’s mother was house
wife; client had loving relation with his mother. Client was 5 siblings, 3 brothers and 2
sisters. Client was eldest of all. Client had decent relation with his siblings. After getting
education he had to enter in the business in which he had no experience. He also had careless
personality. He lost a lot of money and ran out of business. After that whenever he looked at
his siblings he thought of his mistake. He also thought that if he was bit careful about his
business everything would be change. He developed feelings of guilt. This problem
developed the symptoms of depression in client. He also had marital issues. He was
forcefully married to his cousin. He had symptoms of depression before marriage which
become more prominent after marriage. To reduce this client started sniffing. To assess the
client’s current condition mental status examination and beck depression inventory was
applied on client. Mental status examination report states he was sad; he had sense of clothing
and was aware of his problem. Client scored 23 points in beck depression inventory which
showed moderate level of depression of client which might be harmful for client both
physically and mentally. By looking at all the aspects client can be diagnosed as the patient of
depression and addiction.
Psychological and environmental stressors are known as risk factors for depression.
According to Haris (1976) those who are facing long term difficulties were more likely to
appear to disturb. Client had also face difficulties in his life.
Treatment plan
Medication therapy is a core component of recovery for many Dual Diagnosis patients
who are faced with depression. Antidepressant drugs have helped many individuals who
struggle with this disorder cope with their symptoms and lead stable, fulfilling lives. Finding
the right approach to pharmacological treatment can take time and patience, but with the help
of qualified staff who are trained in Dual Diagnosis treatment, prescription drugs can provide
valuable support.
Support, encouragement and motivation are essential tools in the battle against
depression and substance abuse. Clinical depression can drain your energy and make you feel
that rehab is a hopeless cause. Individual counseling, peer group support and family
counseling can give you the strength you need to continue your recovery journey in spite of
the challenges you face.
Prognosis
It might take 3 to 4 months to treat addiction and 8 to 9 sessions for treating
depression.