11 Case Report No 2

(A Case of Drug Abuse)

Bio Data: Name: S/O: Age: Sex: Address: Education: Religion: Occupation: Monthly Income: Siblings: Birth Order: Material Status: Wifes Age: Wifes Education: Wifes Occupation: Children: Father living / dead: Fathers education: Fathers Occupation: Mother living / dead: Mothers Education: Mothers occupation: Socio - economic status: L.A M.H 25 years Male Chack No 85 Junbi, Sargodha. Illiterate Islam Rickshaw Driver Rs. 8000/6 6th Married 21 years Illiterate Housewife One Dead illiterate Labourer Alive Illiterate Housewife Lower class (Brothers 3 Sisters 3)

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Assessment Procedure:
The patients assessment was done through clinical interview, behavioral observation and psychological tests (SDCT, SPM, RISB, HFD, BDI).

Reason & Source of Referral:

The patient was referred by one of my friend and was taken for learning purposes.

Presenting complaints (verbatim):

Symptoms of illness:
Symptoms Loss of appetite Insomnia Restlessness Body Pain Vomiting Headache Addiction Duration 9 days 9 days 9 days 9 days 9 days 9 days 4 years

Behavioral Observations:
The behavior of the patient was cooperative and he responds well. He talked friendly. He showed his determination to get rid of drugs. Eye contact and motor control also was appropriate.

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Pertinent Background Data

Family history: The patient belongs to a lower class. He lived in Sargodha with his family (mother, wife and children). His father died in 1986 at the age of 58 years. The patient mother is illiterate and a house wife. He has three brothers and three sisters. The patients birth order is 6th. The patients elder brother was died in 2008 due to heart attack. His second elder brother is in Prison in case of a murder. There are good relationships among all the siblings. All the siblings are married. The patient is married and he has one child (Boy) and who is three years old. Family history of illness: The patients uncle was drug addict. His mother is suffering from Hepatitis C.

PERSONAL HISTORY:
His birth was normal, no neonatal problems were reported and he grew up normally as other normal children in his family. Early Childhood: He achieved all developmental milestones at appropriate age. He was one year old., when his father was died. Adolescence: He spent most of his time with his friends. He was very found of listening music. He was very good in football. His relations with his siblings were normal. Adulthoods: He was 19 years old, when he became Rickshaws Driver. He was interested in a girl, but she was already engaged with some one else. He was 21 years old, when he got married with her cousin. Then he joined a company of addicts. Due to his sitting with such friends he started to take drugs. The sudden death of his elder brother

14 disturbed him. He had good marital relations but after he becomes a drug addict, his relations with his wife and family affected. He did not commit any other crime in his life except addiction.

Premorbid Personality:
Before his illness, he was socially useful personality. He was a Rickshaw Driver. He had good relations with his friends, family and relatives. His attitude towards moral and religious values was not much concerned.

History of present illness (reported by Patient):

The patient is a drug addict. He uses chars and Heroin. The patient started these drugs in 2006.

Physical / Biological Problems:

The patient has no physical / biological problem except he reports vomiting sometimes.

Psychosomatic Disturbances:
He reports headache, muscular pain, lack of energy and restlessness.

Psychological Assessment:
Clinical interview Behavioral observation Mental status examination Slosson drawing coordination test (SDCT) Standard progressive matrices (SPM) Beck Depression Inventory (BDI) Human figure Drawing (HFD) Rotter Incomplete Sentence Blank (RISB)

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Clinical Interview:
The patient comes to hospital with the complaints of restlessness, body pain, headache and insomnia. Clinical interview was conducted with patient and his mother. The patient has not physical / biological problem except vomiting. Almost four years ago, he joined the company of addicts, due to his sitting with such friends he started the smoking. But with the passage of time he started to take chars and heroin. He spent most of his time with his friends. According to his mother, he was loving and caring person but after he becomes a drug addict, he became very aggressive and often beat her wife. The patient belongs to lower class.

Mental status examination:

A young man, wearing dirty dress and was lying on bed. His personal hygiene was not satisfactory and hairs were not well combed. He was talkative person. He acknowledged that he had teased his mother. He had no interested in religious activities and he had very little knowledge regarding religion. He participated in talk with interest and in active mood. He had no specific hobby. Eye contact and motor control was found normal. Orientation of time place and person was there.

INTERPRETATION OF RESULTS Slosson Drawing Coordination Test (SDCT)

Quantitative analysis: Age Errors Accuracy Score 25 years 25 33 %

16 Qualitative Analysis: According to the SDCT scores, the patients eye-hand coordination does not seems to be intact.

Standard Progressive Matrices (SPM)

Quantitative Analysis: Patients age Total Score Percentile Discrepancies Time taken Intellectual level 25 years 23 5% 4, 1, 0, -2, -1 45 minutes Intellectual defective

Qualitative Analysis: The score indicates that the patient seems to be intellectually defective.

Beck Depression Inventory (BDI):

Quantitative Analysis Score Range Category 28 20 28 Moderate

Qualitative Analysis: The patients scores on the BDI, shows that he has moderate level of due depression.

Rotter Incomplete Sentence Blanks (RISB)

17 Quantitative Analysis

Types of responses C

No of Responses 28

Categories of No of Responses in Reponses C3 C2 categories 7 13 8 5 4 2 0

Values

Total

6 5 4 3 2 1 0 Total

42 65 32 15 8 2 0 164

N P

5 6

C1 N P1 P2 P3 Total

Calculated Score: Cut off Score : Qualitative Analysis:

164 135

According to the RISB scores, the patient seems to have maladjustment. Familiar attitude: The patient showed conflicting attitude at home. For example, Item No. 4: Beck home I get sleep. Item No. 26: Marriage.. Should be done. Item No. 35: My father.. Not remembered. These responses indicate conflicts regarding family. Any how, he has positive feelings about his mother as he respond on item No. 11: A mother.. Is a pious woman.

Social and sexual attitude: He showed conflicting attitude as he responded on item No. 3,5,19,21,and 40

18 Item No. 3: I want to know. Nothing. He showed conflicts regarding addiction as at Item No. 5: I regret Why I take drugs Item No. 19: other people.. Are Selfish. Item No. 21: I Failed . In life. Item No. 40: Most women.. Are Good. All these items are indicating that patient has conflicts in social life. General attitudes: He showed conflicted attitudes again at item No. 6: At bed May Allah give me Rizkay Halal. Item No. 12: I feel. I hurt my mother. Item No. 13: My greatest fear. Death. He showed inferiority complex at the response of item No. 18: My nerves.. Are very weak. A ambiguous and conflicting response was at item No. 30: I hate. A Person. He also showed inferiority complex again at the response of item No. 33: The only trouble.. Earn money.

Character trait related to the patient:

Above mentioned items 13,18,33 indicates that the patient has feelings of inferiority and worthlessness. He showed a bit determination to optimistic as shown on item No. 1: I like.. I wish to up bring my children in a good way. And item No. 24: The future.. The future will be good. He also had a little bit positive attitudes regarding social life as he wants to live as a cooperative society members, as show on item no: 9 and 16, I dislikes.. Make a quarrel. And sports In sports every body should be happy.

Human Figure Drawing (HFD):

Qualitative Analysis:

19 The picture on HFD revels that the patient seems to have immaturity, instability, anxiety, poor coordination, impulsivity, Lack of balance and aggressive behavior towards environment.

Discussion:
From clinical interview and behavioral observation and psychological tests, It was identified that the patient came to hospital with the symptoms of restlessness, body Pain, Insomnia, loss of appetite from 9 days. These complaints are short due to withdrawal of drugs. Different psychological tests were administered like SPM, SDCT, HFD, RISB, BDI. Then therapeutic plan is designed for the treatment of problem.

Conclusion:
The patient history, behavioral observation, clinical interview and test administered showed that he is a patient of Opioid abuse.

DIAGNOSIS:
Axis I: 305.50 292.0 Axis II: Axis III: Axis IV: Axis V : GAF = 42 71.09 Opioid Abuse Opioid Withdrawal No diagnosis None Job dissatisfaction (current)

Case Formulation:

20 The diagnosis was done by clinical interview, behavioral observation and psychological tests. The results of SDCT indicates that the patients eye-hand coordination does not seems to be intact. According to the result of SPM the patient seems to be intellectually defective. According to the score of BDI that the patient seems to have moderate level of depression. The results of RISB indicates that the patient seems to have maladjustment. According to the result of HFD the patient seems to have immaturity instability, anxiety, poor coordination, impulsivity and aggressive behavior. So it is concluded that the patient is suffering from these

problems due to drug abuse. These symptoms and duration meet the criteria of DSM IVTR of Opioid abuse and Opioid withdrawal.

PROGNOSIS:
The prognosis for a psychological intervention is good. At the time of admission, the patient was so much aggressive, restless. He had insomnia and loss of appetite. So, with the help of medicines all the problems of the patient are some what settled now, except addiction. So with the help of biological and psychological treatment and with the co operation of family the patient may become healthy.

RECOMMENDATION
Psychological Treatment: In behavioral modification techniques, aversive technique, assertive therapy and Token economy can be successfully used. Deep breathing and other relaxation should be done for the management of restlessness. Environmental conditions, which force him to take drugs, should be eliminated.

21 Family members should pay attention to him because co operation of the family is very important for patient. Cognitive behavioral treatment should be used to maintain and enhance the better cognition.