Dates of Assessment: September 26, 27, 28 & 30, 2019.
Examiner: Zoha Muslim
Case No: 2
The client is a 25 year old, male, single, Muslim who is a resident of Gawalmandi, Androon Shehar Lahore. He is the second born with one older brother, four younger brothers and five younger sisters. He belongs to low socio-economic status family with nuclear setup. He had done I.COM and was previously working as a police constable.
Referral sources and presenting problems:
ZA was referred by Shabana Shahid (Clinical Psychologist) from Bahria International Hospital for the purpose of psychological assessment. His presenting problems include: tremors, migraines, headaches, body aches and insomnia.
His presenting problems as mentioned above were the resultant of opium withdrawal. The client reported he had started taking drugs due to peer pressure about 2 years back. The client complained of body aches mainly in his shoulders, he claimed it felt as if there was a huge load on his shoulders. Moreover, he complained about migraines and headaches which were worse when he was first admitted, one month back, however, now they happened occasionally. The client also complained of initial insomnia as he had trouble falling asleep at night and felt drowsy all day due to not getting enough sleep. Furthermore, his main complaint was of the tremors he had as a result of heroin withdrawal.
He reported that he took heroin along with alcohol 2 months back which caused a reaction and he was hospitalized in Mayo Hospital, after which the tremors began. His hands and head would shake uncontrollably and when the tremors started he would get self conscious, started stuttering and shaking his legs. Also ZA expressed a lot of guilt about his drug habits which he claimed has ruined his life and he believed his tremors would never stop. Therefore, he believed that he would never be able to lead a normal life. He stated that he feels restless most of the time and has anxiety about getting out of rehabilitation and going back home as he misses his friends and family.
He reported that he had been working for the police for about 4 years and had previously been offered drugs by his friends as well. However, after the demise of his father 2 years ago due to dengue, he gave into peer pressure and began using drugs. He misses his father a lot and wished he was still alive so that he never would have started drug abuse in the first place. He also added that his father would have taken him out of this place (rehab centre) if he was still alive. He reported he had a good relationship with his mother and he misses her immensely. When talking about his siblings he reported to be close with his brothers and two unmarried sisters. He did not have much contact with the 3 married sisters as they live in other cities and seldom came to visit. The client expressed guilt when mentioning his older brother as he thinks he failed him and now he just wants to go home and reconcile with him. ZA further added that his brother was the one who caught him taking heroin when he was under the influence of alcohol and took him to Mayo Hospital. ZA’s older brother was very upset with his drug abuse habits and subsequently got him admitted in rehabilitation centre.
ZA worked as a police constable for 4 years in Naulakha police station. He said that he and his coworkers injected heroin through syringes on their time off and it often caused problems on their duty hours due to the bad side effects. He does not however miss his coworkers and has decided to start his own business after leaving rehabilitation as he does not want to face his coworkers again. The client expressed hostility when mentioning his coworkers whom he blamed for getting him addicted to heroin by stating that he should never have befriended them in the first place and that they were bad people.
The client had a lot of close friends who were mainly his neighbors and school fellows whom he missed a great deal. Most of them are smokers and they were the ones who introduced him to smoking as a teenager. He further added that he could not wait to get back home and meet them again however he would never tell them where he was gone for the last month as he feared they would criticize him.
- Mini Mental Status Examination…………………………..………(MMSE)
- Bender Gestalt Test……………………………………….…………(BGT)
- Human Figure Drawing Test………………..…………….……….(HFD)
- Rorschach Inkblot Test…………………………………………….(ROR)
Behavior during testing sessions:
The client appeared to be lost in his thoughts and had a flat affect during the first session. He was open throughout all the sessions and was able to maintain proper eye contact except for when he talked about his older brother. The client gave off a bad odor and was not properly dressed during sessions and his clothes were always wrinkled. Moreover, his posture was always slouched forward and he appeared anxious whenever his tremors got too out of control. He appeared to be most anxious on drawing tasks as it was difficult for him to hold a pencil and draw because of his tremors e.g. on BGT and HFD tests.
The clients score on MMSE, indicates that there is mild cognitive impairment. The client claimed it was spring however, it was actually autumn. Moreover, he appeared to have a poor long term memory as he was unable to recall two of the three words in item 5. Also he was unable to follow instructions indicating attention and concentration problems. On the last item the client was unable to reproduce all 10 angles of the figure. Hence, his orientation appears to be a bit disturbed.
The clients score on BGT, a psychoneuorological test indicates that he is suffering from some visioconstructive and brain impairment. Therefore, his results are indicative of organic impairment which might be due to his drug addiction, therefore, indicating that he requires psychiatric help.
Projective analysis reveals that the client has an overly dependent personality. Moreover, the protocols reveal that he is highly immature and egocentric. He appears to have voyeuristic and exhibitionistic tendencies. Also, he appears to be secretive about his personal life. ZA is likely to be extremely impulsive in nature and has poor emotional and impulsive control which in turn effects his interpersonal functioning. Projective analysis also reveals that the client has infantile aggression and oral dependant passive aggression. Client uses the defense mechanism of regression frequently. Moreover, he tends to avoid his problems particularly related to body.
Projective analysis further reveals that the client has nurturance needs which are not being met. Furthermore, analysis indicates psychosexual immaturity and possibilities of sexual inadequacy. ZA appears to be highly rigid and inflexible when it comes to accepting change. The protocols frequently indicate alcoholism and substance abuse tendencies. Moreover, the protocols are indicative of brain damage and difficulty in cognitive shifting. ZA appears to have serious levels of maladjustment along with intellectual deterioration due to possible brain and nervous damage
292.0 (F11.23). Opioid Withdrawal, on maintenance therapy, in a controlled environment.
On the basis of his overall evaluation, available resources and severity of problem his prognosis seems to be less satisfactory.
- Treatments for opioid misuse and addiction include medicines. Methadone and buprenorphine can decrease withdrawal symptoms and cravings. They work by acting on the same targets in the brain as other opioids. They restore balance to the parts of the brain affected by addiction.
- Medication-assisted therapy (MAT), which includes medicines, counseling, and behavioral therapies are recommended. This offers a “whole patient” approach to treatment, which can increase chance of a successful recovery.
- Residential and hospital-based treatment offer people with depression advice on sleep hygiene if needed, including, establishing a schedule of regular sleep and wake times, avoiding excess eating or smoking before sleep, creating a proper environment for sleep, taking regular physical exercise etc.
- Psychological counseling may be highly beneficial, which may include setting goals, talking about setbacks, and celebrating progress. Counseling often includes specific behavioral therapies such as: (1) Cognitive-behavioral therapy (CBT) helps recognize and stop negative patterns of thinking and behavior. It teaches coping skills, including how to manage stress and change the thoughts that cause opioid cravings. (2) Motivational enhancement therapy helps build up motivation to stick with the treatment plan. (3) Contingency management focuses on giving incentives for positive behaviors such as staying off the opioids. (4) Group counseling, which can help the client feel that he is not alone with his issues. (5) Family counseling/ includes partners or spouses and other family members who are close to the client. It can help to repair and improve your family relationships and home environment.
Dr. Shabana shahid Khan
|Student of BS Psychology