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Table of Contents
PART I

Bio Data of the Client 2

Reason of Referral 3
Presenting Complaints 3
Other Symptoms Observed 4
History of Present Illness 4
Personal History 5
Family History 5
Medical History 5

Premorbid Personality 5
Psychological Assesement 6

Informal Assessment 6
Interview 6

Mental Status Examination 6

Formal Assessment 7

Dast-10 7
RISB 7

HTP 8
Cross Cutting Measure 8

Daignosis 9
Differential Daignosis 9

Case Formulation 10
PART II

Current Treatment 10
Intervention Plan 11
Cognitive Behavioral Therapy (CBT) 11

Motivational Interviewing (MI) 11

Relapse Prevention and Psychoeducation 11

IPT 11
Family Therapy 12

Prognosis 12
Refferences 13
Anexures
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PART 1

Bio Data

Name HN

Sex Male

Age 29

Date of birth 1995

Residence I/8 Islamabad

Education 9th Pass

Family Structure Nuclear

Family Size Six

Father Status Alive

Mother Status Alive(House Wife)

No of Siblings 3 brothers including him 1 sister

Birth Order 1st Born

Source of Referral Voluntarily

Informant Himself

Institute UmmedeShifa Rehablitation Center

Address Bani Gala Islamabad

No of Sessions 5
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‫‪Reason for Referral‬‬

‫‪The patient came to the rehabilitation center voluntarily, accompanied by his father, seeking‬‬

‫‪treatment for substance abuse, including cannabis, alcohol, and cigarettes.‬‬

‫‪Presenting Problems‬‬

‫"میں ‪ 30‬سال کا ہوں اور میرے والد ایک پراپرٹی ڈیلر ہیں۔"‬

‫"میں اپنے والد کے ساتھ زیادہ جڑا ہوا ہوں کیونکہ میری والدہ کے ساتھ میرا تعلق ہمیشہ اچھا نہیں رہا۔"‬

‫میری شادی کو چند سال ہو چکے ہیں‪ ،‬لیکن میری بیوی کے ساتھ میرے تعلقات بہت خراب ہیں کیونکہ مجھے لگتا ہے کہ وہ‬

‫میرے چھوٹے بھائی کے ساتھ دھوکہ دے رہی ہے‬

‫"اس کی وجہ سے میں نے اس پر مکمل طور پر بھروسہ کھو دیا ہے اور میں بہت اکیال محسوس کرتا ہوں۔"‬

‫"بچپن میں‪ ،‬میں بہت تنہائ پسند تھا اور دوست بنانے میں مجھے کوئی دلچسپی نہیں تھی۔"‬

‫"اسکول میں مجھے پڑھائی میں مشکالت آئیں اور نائنتھ کالس میں فیل ہونے کے بعد میں نے پڑھائی چھوڑ دی۔"‬

‫میرے لیے غیر نصابی سرگرمیوں میں حصہ لینا کبھی بھی دلچسپی کا باعث نہیں بنا اور میں نے کبھی بھی دوست بنانے کی "‬

‫"کوشش نہیں کی۔‬

‫جب میں ‪ 22‬سال کا تھا‪ ،‬تو میں نے سب سے پہلے چرس استعمال کرنا شروع کیا‪ ،‬اور اس کے بعد شراب اور سگریٹ کا "‬

‫"استعمال بھی بڑھا لیا۔‬

‫"اب میں روزانہ ‪ 40‬سگریٹ پیتا ہوں اور حالیہ دنوں میں میتھمفیٹامین (آئس) بھی استعمال کرنا شروع کر دی ہے۔"‬

‫”میرے نشے کی وجہ سے میری نیند متاثر ہوئی ہے اور کبھی کبھار مجھے لوگ بھی دکھائی دیتے ہیں۔"‬

‫"میرے بیوی کے ساتھ تعلقات کی وجہ سے جذباتی طور پر میں بہت الجھا ہوا ہوں۔"‬

‫"عالج کے بعد میں اپنا کاروبار شروع کرنا چاہتا ہوں‪ ،‬لیکن مجھے پہلے ان مسائل سے نمٹنا ہوگا۔"‬
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Other Symptoms Observed

1.Dependency (Emotional)

2.Anger Issues

3.Paranoia

4.Mistrust towards People

5.Less decision making ability often ask for fathers validation

6.Restlessness

7.Anxiousness

8.Less interest in studies

9.Less Sociable usually not make friends

10.Introversion Tendencies

History of Present Illness:

The patient, a man in his early thirties, has been struggling with substance use for about 10 years, starting

with cannabis. Over time, he also began using alcohol and cigarettes, smoking around 40 cigarettes a day.

Recently, he started using methamphetamine (ice) about a week before coming to the rehab center for

treatment. The patient reports having serious mental health issues linked to his drug use, such as

hallucinations (hearing and seeing things that aren't there), trouble sleeping, and feelings of guilt,

hopelessness, and even suicidal thoughts. These problems have gotten worse with the use of ice. He also

experiences sexual hallucinations and sees things, like drops of water, in a sexual way when using drugs. The

patient is also very upset about problems in his marriage, as he believes his wife has cheated on him with his

younger brother. This has led to a lot of mistrust of others and a feeling of being isolated. He says he has

never been very social, even as a child, and has always had difficulty trusting people.He once tried to commit

suicide by jumping from a 7th-floor building, likely due to the emotional pain caused by his drug use and

relationship issues. He often feels like crying and helpless, and these feelings have become stronger as he

continues to use drugs. Although the patient is unhappy with the treatment he’s receiving in the rehabilitation

center, he says he wants to change and improve his life. His case shows that substance use disorder is the
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main problem, but it is deeply connected to mental health issues, such as depression and hallucinations,

which need to be addressed together in treatment.

Personal History

The client is a male in his early thirties, the first-born in a family of five. He has three younger brothers and

one sister, with a closer relationship to his father, who works as a property dealer. He reports a strained

relationship with his mother and has experienced significant marital dissatisfaction due to a perceived affair

between his wife and his younger brother, leading to feelings of betrayal and mistrust.Growing up, the client

was emotionally withdrawn and struggled socially, with no interest in extracurricular activities or making

friends. He had difficulty in school and dropped out after failing the 9th grade, showing little desire for further

education. His social isolation continued into adulthood, where he engaged in short online relationships. The

client began using cannabis at age 22 and developed a dependency on alcohol and cigarettes, smoking 40

cigarettes a day. More recently, he began using methamphetamine. His substance use has led to sleep

disturbances, hallucinations, and emotional dysregulation. He is financially dependent on his father, as he is

not employed. Despite these challenges, the client expresses a desire to change and is motivated to start his

own business after treatment. However, his ongoing emotional and relational issues may hinder his recovery

process.

Family History

The client comes from a family of six and is the eldest sibling. He reported a close relationship with his father

but noted marital dissatisfaction due to his wife’s infidelity. A brother has been diagnosed with depression,

suggesting a possible genetic predisposition to mental health challenges within the family.

Medical History

The client reported no significant physical illnesses. However, his sleep disturbances and hallucinations are

directly linked to his substance use, particularly ice, which has leads to these issues.

Premorbid Personality

The patient’s premorbid personality reflects a pattern of social withdrawal, mistrust, and emotional

dependence on others. From a young age, he exhibited a lack of sociability, evident in his limited ability to

make friends and his disinterest in extracurricular activities during school. He avoided forming close

relationships and reported excessive mistrust toward people, even before substance use. These traits suggest
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a predisposition toward introversion and a lack of adaptive social skills. Academically, the patient struggled,

showing a lack of interest in studies and failing to progress beyond the 9th grade. This indicates possible low

self-confidence and limited motivation in structured settings, further isolating him from peer groups and

hindering his development of a supportive social network. Emotionally, the patient displayed a high

dependency on his father, to whom he was more attached than other family members. His dependency traits

are further reflected in the House-Tree-Person (HTP) test results, where his drawings suggested feelings of

helplessness, dependency on others, and isolation. These emotional characteristics likely contributed to his

vulnerability to maladaptive coping mechanisms, such as substance use, to manage his distress and loneliness.

Overall, his premorbid personality reflects a foundation of social withdrawal, mistrust, emotional dependency,

and low self-esteem, which created a predisposition to maladaptive behaviors and poor stress management.

This personality profile likely influenced his susceptibility to peer pressure and substance use as an attempt to

fill the void created by his isolation and emotional struggles.

Psychological Assessment

Informal Assessment

Interview

The interview provided detailed insights into the patient’s background and presenting issues. He reported a

history of substance abuse, including the use of cannabis for 10 years, alcohol for nearly a 9-10 years, and ice

just one week prior to admission. The patient openly discussed feelings of guilt, mistrust, and marital

dissatisfaction, particularly focusing on the betrayal by his wife with his younger brother. He also shared his

struggles with sleep disturbances, hallucinations, and suicidal ideation, including a prior suicide attempt.

Despite these challenges, the patient displayed motivation to change, expressing a desire to start a business

after completing treatment.

Mental State Examination (MSE)

The mental state examination revealed that the patient was well-oriented to time, place, and person. He

demonstrated an understanding of his current situation and showed insight into his problems. However, he

reported significant issues with concentration and memory, which he attributed to prolonged substance use.

His thought process was marked by suspiciousness, as he believed that people were generally untrustworthy.

These cognitive and emotional patterns provided important context for understanding his mental health

challenges.
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Behavioral Observation

During the assessment, the patient exhibited signs of restlessness, which reflected his internal agitation.

Despite this, his mannerisms were generally normal, and he maintained appropriate behavior throughout the

session. He appeared motivated to engage in the rehabilitation process and demonstrated openness in

discussing his struggles. This willingness to participate and his motivation for self-improvement were key

strengths observed during the session. These behavioral observations further highlighted the urgency of

addressing his substance use and emotional challenges to support his recovery journey.

Formal Assessment

The formal assessment involved administering psychological tests to evaluate the severity of the patient’s

substance use, emotional functioning, and personality dynamics. These included the Drug Abuse Screening

Test (DAST-10), Rotter Incomplete Sentences Blank (RISB), House-Tree-Person (HTP) test and the DSM-5

Self Related Level 1 Cross Cutting Measur-Adult, LEVEL 2- Substance Use-Adult. Each test provided unique

insights into the patient’s psychological and emotional state.

Drug Abuse Screening Test (DAST-10)

The DAST-10 is a brief, standardized self-report screening tool designed to assess the degree of substance

abuse problems. It evaluates various aspects of substance use, such as its impact on relationships,

responsibilities, and physical health, to determine the severity of addiction. DAST-10 (Drug Abuse Screening

Test - 10) is an objective screening tool. It is designed to assess the presence and severity of substance use

problems, specifically focusing on drug abuse and dependence. The DAST-10 is a self-report questionnaire

consisting of 10 yes/no questions, which the patient answers based on their experiences with drug use in the

past 12 months. The patient scored 9 out of 10, which falls in the severe range, indicating a serious substance

dependence requiring immediate and intensive intervention. This score reflects the pervasive impact of his

substance use on his daily functioning, including health complications, psychological disturbances, and

interpersonal conflicts.

Rotter Incomplete Sentences Blank (RISB)

The RISB is a semi projective psychological test designed to assess an individual’s adjustment and emotional

functioning through their responses to incomplete sentences. The test measures themes such as interpersonal

relationships, self-concept, and attitudes toward life. The patient scored 101, suggesting minor social
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adjustment issues. His responses indicated feelings of mistrust, emotional dependency, and insecurity, aligning

with his reports of difficulty forming meaningful relationships and mistrusting others. These findings also

reflect his struggles with emotional self-regulation and unresolved conflicts related to his substance use and

interpersonal challenges.

House-Tree-Person (HTP) Test

The HTP test is a projective drawing test used to evaluate an individual’s perceptions of themselves and their

environment. It explores aspects of personality, emotional functioning, and underlying conflicts through

drawings of a house, a tree, and a person. House Drawing: The patient’s depiction of a happy house reflected

his idealized desire for stability and a fulfilling family life. However, this contrasts sharply with his current

feelings of guilt, mistrust, and marital dissatisfaction, highlighting a discrepancy between his aspirations and

reality.Tree Drawing: The isolated tree without fruits or surrounding elements suggested feelings of

loneliness, unproductiveness, and lack of purpose. This aligns with his emotional state and his sense of

stagnation in life.Person Drawing: The absence of arms and raised legs in the drawing indicated feelings of

helplessness and dependency. This reflects his over-reliance on his father for emotional and financial support,

as well as his perceived lack of control over his life.

Cross Cutting Measure

The patient's Level 1 score of 12 indicates moderate symptoms across various psychological domains,

highlighting significant distress. The patient is experiencing notable emotional difficulties, including

depressive symptoms, such as feelings of guilt, hopelessness, and suicidal ideation. The presence of crying

spells and mistrust toward others suggests a fragile emotional state that affects interpersonal functioning.

Additionally, the patient's substance use of cannabis, alcohol, cigarettes, and ice exacerbates his

psychological struggles, contributing to hallucinations, sleep disturbances, and impaired decision-making.

His psychotic symptoms, particularly auditory and visual hallucinations, seem to be directly linked to

substance use, which significantly impacts his emotional and cognitive functioning. The patient's Level 2

score of 9 reveals severe substance use disorder. This score suggests that substance use is a major issue in

the patient’s life, causing significant impairment. The patient’s tolerance to substances, withdrawal

symptoms, loss of control, and continued use despite negative consequences point to a high level of

dependence. The continued substance use despite marital dissatisfaction, hallucinations, and overall

dysfunction demonstrates that substance use is central to his struggles. The combined scores reflect the severe
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impact of substance use disorder on his life, suggesting that treatment should focus on addressing his

addiction, alongside managing the co-occurring psychological issues like depression and psychosis.

Diagnosis (Tentative)

Cannabis Use Disorder, Severe (F12.20).

The patient’s long-standing cannabis use of over 10 years, along with symptoms such as continued use despite

interpersonal and social problems, increased tolerance, and failed attempts to quit, clearly align with the

criteria for this diagnosis. His substance use is the central issue driving his psychological, emotional, and

behavioral difficulties, including hallucinations, mistrust, marital dissatisfaction, and suicidal ideation.

Differential Diagnosis

Substance/Medication-Induced Psychotic Disorder (F16.259).

The patient’s hallucinations—both auditory and visual—occur primarily after substance use, particularly ice

and cannabis. These symptoms resolve when the substances are not in use, strongly suggesting a causal link

to his substance abuse rather than an independent psychotic disorder.

Case Formulation

The patient is a 29-year-old married male who presented for treatment of substance abuse, reporting a history

of cannabis, alcohol, and nicotine use spanning over 10 years. His substance use escalated following

significant interpersonal and emotional distress, including marital dissatisfaction due to his wife’s infidelity

with his younger brother. He exhibits symptoms such as auditory and visual hallucinations following drug use,

mistrust toward others, sleep disturbances, guilt, and a history of a suicide attempt. His dependency on

substances appears to serve as a maladaptive coping mechanism for underlying emotional pain, feelings of

isolation, and low self-esteem. The patient’s premorbid personality was marked by social withdrawal, mistrust,

and emotional dependency, contributing to a lack of healthy social connections and coping strategies. This

predisposition, combined with his exposure to substance use through a friend, led to his long-term dependence.

His mistrust and inability to form close relationships further compounded his isolation, leading to reliance on

substances to manage distress and perceived inadequacies. Formal assessments provide insight into the

severity and consequences of his substance use and emotional challenges. His DAST-10 score of 9 indicates

severe substance dependence, while his RISB score of 101 reflects difficulties in social adjustment,

dependency, and mistrust. The HTP test highlights themes of helplessness, isolation, and unproductiveness,
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consistent with his feelings of being unfulfilled and emotionally stagnant. These findings underscore the

complex interplay between his substance use, emotional struggles, and interpersonal conflicts. Currently, the

patient demonstrates motivation to change, evidenced by his voluntary admission to treatment and expressed

desire to establish a business after rehabilitation. However, his reliance on his father for emotional and

financial support, coupled with his mistrust and emotional dependency, suggests a need for targeted

therapeutic interventions the patient’s case formulation indicates that his substance use disorder is driven by

emotional pain, interpersonal conflicts, and maladaptive coping strategies rooted in his premorbid personality

and life experiences. A comprehensive treatment plan addressing his substance use, emotional regulation,

interpersonal relationships, and future goal-setting will be critical for recovery and sustained well-being.

PART II

Current Treatment

The patient is currently undergoing treatment at a rehabilitation center, focusing on addressing his substance

use disorder and associated psychological challenges. His treatment plan is designed to address his severe

dependence on cannabis, alcohol, and nicotine, alongside managing the emotional and interpersonal

difficulties that have contributed to and resulted from his substance use.

I. Detoxification and Substance Use Management

The first phase of treatment involves detoxification to manage withdrawal symptoms and stabilize the patient

physically. This includes monitoring his health and providing medical support to reduce cravings and prevent

relapse. Counseling sessions aim to educate him about the impact of substances on his mental and physical

health.

II. Individual Therapy

The patient is receiving individual psychotherapy to explore the root causes of his substance use. Therapeutic

approaches such as Cognitive Behavioral Therapy (CBT) are being utilized to help him identify and challenge

maladaptive thought patterns, develop healthier coping mechanisms, and manage triggers for substance use.

Therapy also focuses on addressing guilt, mistrust, and feelings of betrayal stemming from his marital issues

and interpersonal conflicts.

III. Group Therapy Sessions

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Group therapy sessions provide the patient with a supportive environment to share his experiences and learn

from others facing similar challenges. These sessions aim to reduce feelings of isolation, improve his

interpersonal skills, and foster a sense of belonging.

IV. Psychoeducation

The patient is participating in psychoeducation sessions to increase his awareness of the relationship between

substance use, mental health, and overall well-being. These sessions also focus on teaching him stress

management techniques, emotional regulation strategies, and the importance of building a structured daily

routine.

V. Behavioral and Relapse Prevention Planning

Behavioral interventions are helping the patient replace maladaptive behaviors with healthier alternatives. A

relapse prevention plan is being developed to identify high-risk situations, manage cravings, and build

resilience against potential relapses. The patient is learning practical skills to maintain abstinence, such as

developing new hobbies and exploring productive activities.

VI. Family Counseling

Given the significant influence of family dynamics on the patient’s mental health, family counseling sessions

are being arranged. These sessions aim to improve communication, address unresolved conflicts, and foster a

supportive environment for the patient’s recovery.

Intervention Plan

1. Cognitive Behavioral Therapy (CBT) Objective: To address the patient’s maladaptive thought patterns

and substance use. CBT will be central to this treatment, focusing on helping the patient identify and challenge

his distorted thinking, particularly his mistrust of others and feelings of helplessness. By learning healthier

coping mechanisms and emotional regulation techniques, the patient can replace substance use as a way to

manage distress with more constructive behaviors.

2. Motivational Interviewing (MI) Objective: To increase the patient’s motivation for change and enhance

his commitment to recovery. MI is particularly important as the patient has shown some insight into his

problems and expressed a desire to change. MI will help resolve any ambivalence about recovery by exploring

his reasons for wanting to change, reinforcing his desire to build a better future (such as starting a business),

and increasing his commitment to treatment.

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3. Relapse Prevention and Psychoeducation Objective: To reduce the risk of relapse and educate the patient

about the effects of substance use. Relapse prevention will help the patient develop strategies to cope with

cravings and high-risk situations. Psychoeducation will give the patient a deeper understanding of the impact

of cannabis, alcohol, and nicotine on his mental health, reinforcing the importance of maintaining sobriety for

emotional stability and well-being.

4. Interpersonal Therapy (IPT) Objective: To address interpersonal issues, particularly marital

dissatisfaction and mistrust .Since the patient’s marital problems are a major stressor, IPT will focus on

improving his relationship skills and resolving conflicts related to betrayal and trust. This therapy will help

the patient process the hurt from his wife’s infidelity and work on rebuilding healthy communication patterns.

5. Family Therapy Objective: To improve family dynamics and strengthen the support system for recovery.

Given the patient’s close attachment to his father, family therapy will help to address family dynamics and

promote a supportive environment for his recovery. Involving family members can encourage understanding,

reduce conflict, and provide the patient with emotional support during the recovery process.

These interventions are selected based on their ability to target both the psychological and emotional aspects

of the patient’s condition while addressing his substance use. A combination of CBT, MI, relapse prevention,

IPT, and family therapy provides a holistic approach to treatment, focusing on immediate recovery needs and

long-term well-being.

Prognosis

The prognosis for the patient appears cautiously optimistic, provided that he engages actively with the

treatment plan and maintains his motivation to change. His insight into his condition and willingness to seek

help indicate a readiness to address his challenges, which is a positive factor in predicting recovery outcomes.

However, his long history of substance abuse, including cannabis, alcohol, and cigarettes, as well as the recent

use of stimulants (ice), poses significant challenges to achieving sustained sobriety.His psychological test

results also suggest areas requiring focused intervention. The Drug Abuse Screening Test (DAST) score of 9

indicates severe addiction issues, necessitating intensive rehabilitation and relapse prevention strategies. The

HTP test results reveal feelings of dependency, helplessness, and isolation, which may impede his recovery if

left unaddressed. His social mistrust and marital dissatisfaction could further complicate interpersonal

relationships during and after rehabilitation.On the positive side, his expressed desire to establish a business

after treatment indicates goal-oriented thinking, which can serve as a motivator for long-term recovery.
 13

Additionally, the support of his father and a structured rehabilitation program may provide the stability needed

for progress. With a comprehensive approach that includes counseling for substance abuse, addressing

underlying emotional and interpersonal issues, and fostering social adjustment skills, the patient has a

promising chance of achieving better mental health and functional recovery. However, consistent follow-ups

and a robust aftercare plan will be critical to maintaining progress post-rehabilitation.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

American Psychiatric Publishing.

Beck, A. T., & Weishaar, M. E. (2005). Cognitive therapy: Basics and beyond (2nd ed.). Guilford Press.

DiClemente, C. C., & Maddux, J. F. (2009). Motivational interviewing and the stages of change. Guilford

Press.

Marlatt, G. A., & Donovan, D. M. (2005). Relapse prevention: Maintenance strategies in the treatment of

addictive behaviors (2nd ed.). Guilford Press.

Markowitz, J. C., & Weissman, M. M. (2012). Interpersonal psychotherapy: A clinician's guide. Guilford

Press.

Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford

Press.

Norton, P. J., & Price, S. (2008). The effectiveness of cognitive-behavioral therapy for anxiety and depression.

Clinical Psychology Review, 28(3), 337-356. https://doi.org/10.1016/j.cpr.2007.07.005

Sinha, R. (2001). The role of stress in addiction relapse. Clinical Psychology Review, 21(4), 489-516.

https://doi.org/10.1016/S0272-7358(00)00037-6

Substance Abuse and Mental Health Services Administration. (2015). Substance use treatment and recovery

services. U.S. Department of Health and Human Services. https://www.samhsa.gov