case q 1

Case Study
Submitted to:
Mam Shumaila
Submitted by:
Department of psychology
University of Sargodha Gujranwala campus
Case report
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 present illness
The client has 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.
Family history
Client’s father was an officer. He belongs to family of moderate socio economic status.
His father has 2 wives. They all live together. Client step mother has no child. Client has good
relations with his family members except his brother. He lacks the feeling of acceptance from his
brother. His father supports him financially. His mother comes to meet him in the hospital
mostly. He is more attached to his mother. He has loving relation with his sister.
Educational history
Client has visited school. He is matric pass. He quit his study in
Personal history
Client is the eldest of all his siblings. He is 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.
Love relation history
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.
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. 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.
Assessment tools
The assessment tool used in the case report was Beck Anxiety Inventory.
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
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.
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