Internship Report

Supervisor

Mam Ayesha Andleeb

By

Duaa Naeem

Roll No. 881

M.Sc. Applied Psychology

Session (2018-2020)
4th Semester

DEPARTMENT OF APPLIED PSYCHOLOGY

The Islamia University Bahawalpur
Internship Report

Department of Applied Psychology

The Islamia University Bahawalpur

Internship case report submitted to the department of the Applied Psychology, Islamia

University of Bahawalpur, in the fulfillment of the degree of M.Sc. Applied psychology.

2018-2020
Internship Report

Approved By

_________________________
Supervisor

_________________________
External Examiner
Declaration

It is here by solemnly that the internship reports have been done by me and it has not

been presented by anyone of his partial fulfillment of any degree. It is further declared

that

there is no any sort of copy and fake reports.

Duaa Naeem
ACKNOWLEDGEMENT

It is my extreme wish, God blessings and my dear parents’ prayers that my higher
education dream came true by the wonderful inspiration of the great Psychologist of
our time Ma’am Fouzia who is my supervisor too which is also a proud honor for me.
Ma’am Ayesha Andleeb deserves special mention for her consistent guidance and
encouragement throughout my reports work. I duly acknowledged the contributions of
Ma’am Ayesha Andleeb and all of my class fellows who will remain a precious asset to
me in my memories.

Duaa Naeem
Table of Content

Serial no. Content Pg no.

1. Schizophrenia 1

2. Alcohol abuse 7

3. Post-traumatic stress disorder 12

4. Attention deficit hyperactivity disorder 19

5. Cannabis withdrawal 25
Case No. 01

Schizophrenia

1
Summary
N is a 25 years old man. He is experiencing severe pain in his right arm. He is diagnosed
as patient of Schizophrenia. He belongs to a lower class family. He is uneducated. He has
5 siblings, 3 brothers and 2 sisters. His parents are alive. He is unmarried. He was
suffering from severe pain in his right arm since past 4 years. He is describing himself as
an entity equivalent to ALLAH. He was talkative. He was unaware of his clothes. He was
cooperative.
Introduction
Schizophrenia is a chronic and severe mental disorder that affects how a person thinks,
feels and behaves. People with schizophrenia may seem like they have lost touch with
reality. Although schizophrenia is not as common as other mental disorders, the
symptoms can be very disabling.

Symptoms of schizophrenia usually start between ages 16 and 30. In rare cases, children
have schizophrenia too. The symptoms fall into three categories: positive, negative and
cognitive.

Positive symptoms: ‘Positive’ symptoms are psychotic behaviors not generally seen in
healthy people. Symptoms include:

● Hallucinations

● Delusions

● Thought disorders

● Movement disorders.

Negative symptoms: ‘Negative’ symptoms are associated with disruptions to normal

emotions and behaviors. Symptoms include:

● Reduced feelings of pleasure in everyday life.

● Difficulty beginning and sustaining activities

● Reduced speaking.

Cognitive symptoms: For some patients, the cognitive symptoms of schizophrenia are
subtle but for others they are more severe. Symptoms include:

● Trouble focusing or paying attention.

● Problems with working memory.

Diagnostic Criteria:
A. Two (or more) of the following, each present for a significant portion of time
during a 1-month period (or less if successfully treated. At least one of these must
be :
B. For a significant portion of the time since the onset of the disturbance, level of
functioning in one or more major areas such as work, interpersonal relations or
selfcare, is markedly below the level achieved prior to the onset.
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month
period must include at least 1 month of symptoms ad may include periods of
prodromal or residual symptoms. During these prodromal or residual periods, the
signs of the disturbance may be manifested by only negative symptoms or by two
or more symptoms listed in Criterion A present in an attenuated form.

3
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic
features have been ruled out because either 1) no major depressive or manic
episodes have occurred concurrently with the active-phase symptoms, or 2) if
mood episodes have occurred during active-phase symptoms, they have been
present for a minority of the total duration of the active and residual periods of the
illness.
E. The disturbance is not attributable to the physiological effects of a substance.
F. If there is a history of autism spectrum disorder or a communication disorder of
childhood onset, the additional diagnosis of schizophrenia is made only if
prominent delusions or hallucinations.

Differential Diagnosis:
Schizoaffective disorder:

A diagnosis schizoaffective disorder requires that a major depressive or manic episode

occur concurrently with active-phase symptoms and that the mood symptoms be present
for a majority of the total duration of the active periods.

Delusional disorder:

Delusional disorder can be distinguished from schizophrenia by the absence of the other
symptoms characteristic of schizophrenia.

Schizotypal personality disorder:

Schizotypal personality disorder may be distinguished from schizophrenia by

subthreshold symptoms that are associated with persistent personality features.
Post-traumatic stress disorder:

Post-traumatic stress disorder may include flashbacks that have a hallucinatory quality
may reach paranoid proportions. But a traumatic event and characteristic symptoms
features relating to reliving or reacting to the event are required to make the diagnosis.

Bio-Data
Name: N

Age: 25

Gender: Male

No. Of Siblings: 3 brothers and 2 sisters

Birth Order: 3rd

Education: Uneducated

Marital status: Single

Source of Referral:
The client was referred through OPD on 27th of June on time 11:35 am.

Reason of Presentation:
Muscle pain on right arm.

Informant:
Himself

Presenting Complaints:
The client was suffering from muscle pain on right arm from 3-4 months. The patient’s
was suffering from psychotic symptoms. Grandiosity appeared from his talk. He
considered himself something equivalent to ALLAH. His talk was incoherent and was
talkative. He was giving pressure to his words. His appetite and sleep duration was
normal.
History of Presenting Illness:
The client told that he had an accident 4 years old. He was normal before the accident. He
used to do his domestic work by himself. There is no family psychiatry disorder. He was
very talkative and has pressure of speech.

Past Psychiatric History:

There is no psychiatry history of the client.

Past Medical History:

The client had an accident 4 years ago. His right arm was full damaged in the accident.

Family History:

● Father : N. A

● Mother: F. b

● Siblings: 3 brothers and 2 sisters

● Socio-Economic Status family: Lower class

● History of Psychiatric Illness: NILL

Personal History:

● Birth Injury: NILL

● Childhood Disease: NILL

5

● Developmental Milestones: The client has achieved his milestones at an

appropriate age.
● Schooling:

⮚ Starting Age: 7 years

⮚ Achievements: NONE

⮚ Behaviour relations with

✔ Peers: not so good

✔ Teachers: Bad

● Puberty at the age of: Client has reached puberty at an appropriate age.

● Sexual Abuse: NO

● Drug abuse: Yes.

Premorbid personality:

● Relationship with

⮚ Family: Normal

⮚ Peers: NO social circle.

Present mental state examination:

● Appearance & Behaviour:

The client was wearing black printed T-shirt and black trouser. The client was wearing
neat and clean dress which indicate that he had a sense of hygiene but his hair
were not combed properly. He was answering with blank face i.e. no face
expression. Therefore, the patient was cooperative and friendly. He answered
every question without getting angry.
● Speech: Talkative, pressured, whispered, mumbled and incoherent.

● Mood: Flight of Ideas, knight’s move.

● Orientation in time, place & person: The client was aware that he is in Hospital
but do not know about the time.

Treatment:
Because the causes of schizophrenia are still unknown, treatments focus on elimination
the symptoms of the disease. Treatments include:

● Antipsychotics:
Antipsychotic medications are usually taken daily in pill or liquid form. Some
antipsychotics are injections that are given once or twice a month. Some people
have side effects when they start taking medications, but most side effects go
away after a few days. Doctors and patients work together to find the best
medication or medication combination and the right dose.

● Psychosocial Treatments:
These treatments are helpful after patients and their doctor find a medication that works.
Learning and using coping skills to address the everyday challenges of
schizophrenia helps people to pursue their life goals such as attending school or
work. Individuals who participate in regular psychosocial treatment are less likely
to have relapses or be hospitalized.

Formulation of Case:
Schizophrenia caused marked distress or significantly interfere with the person’s normal
routine. Occupational functioning and usual social activities suffered badly due to his
illness. He does not recognize that his thoughts are unreasonable. His sleeping pattern is
disturbed and his appetite is increased.
Case No. 02

Alcohol Abuse
7

Summary
M. R is a 32 years old man. He is a drug addict patient having aggressive behavior. He
belongs to poor class family. He never went to school. He has 4 siblings, 2 brothers and 2
sisters. His parents are alive. He is married. He has one child (son). His wife is a
housewife. He was showing extreme reactions to the normal routine work. Due to his
behavior, his family has outcast him. He is jobless. He used to beat his wife and child
without any specific reason. He was well dressed. He was not cooperative and was
showing aggressive behavior.
8

Introduction
Drug addiction also called substance use disorder is a disease that affects a person’s brain
and behavior and leads to an inability to control the use of a illegal drug or medication.
Substances such as alcohol, marijuana and nicotine also are considered drugs. The risk of
addiction and how fast you become addicted varies by drug. Some drugs such as opioid
painkillers have a higher risk and cause addiction more quickly than others. Drug
addiction symptoms or behaviors include:

● Feeling that you have to use the drug regularly – daily or even several times a
day.
● Taking larger amounts of the drug over a longer period of time

● Needing more of the drug to get the same effect.

● Spending money on the drug even though you can’t afford it.

● Doing things to get the drug that you normally wouldn’t do such as stealing.

● Failing in your attempts to stop using the drug.

● Experiencing withdrawal symptoms when you attempt to stop taking the drug.

Diagnostic Criteria:
A. A problematic pattern of alcohol use leading to clinically significant impairment
or distress as manifested by at least two of the following, occurring with a 12-
month period:
1. Alcohol is often taken in larger amounts or over a longer period than was
intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control
alcohol use.
3. Craving, or strong desire or urge to use alcohol.
4. Recurrent alcohol use resulting in a failure to fulfil major role obligations at
work, school or home.
5. Important social, occupational or recreational activities are given up or
reduced because of alcohol use.
6. Recurrent alcohol use in situations in which it is physically hazardous.

Differential diagnosis:
Non-pathological use of alcohol:

The key element of alcohol use disorder is the use of heavy doses of alcohol with
resulting repeated and significant distress or impaired functioning. While most drinkers
sometimes consume enough alcohol to feel intoxicated only a minority ever develop
alcohol use disorder.

Sedative, hypnotic or anxiolytic use disorder:

The signs and symptoms of alcohol use disorder are similar to those seen in sedative,
hypnotic or anxiolytic use disorder. the two must be distinguished, however because the
course may be different especially in relation to medical problems.

Conduct disorder in childhood and adult antisocial personality disorder: Alcohol use
disorder along with other substance use disorders is seen in the majority of individuals
with antisocial personality and pre-existing conduct disorder. because these diagnoses are
associated with an early onset of alcohol use disorder as well as a worse prognosis, it is
important to establish both conditions.
Bio-Data
Name: M. R

Age: 32

Gender: Male

No. Of Siblings: 2 brothers & 2 sisters

Birth Order: 1st

Education: Uneducated

Marital status: Married

Source of Referral:
The client was referred from Hamza Care Medical Rukanpur. By Dr. Fayaz on 11-7-2019
because of his excessive aggression.

Reason of Presentation:
High blood pressure

Informant:
Himself

Presenting Complaints:
Client’s behavior was extreme aggressive with his family members. He used to beat his
wife and once killed a chicken with a stone due to aggression.

10

History of Presenting Illness:

Client describes that he is suffering from high blood pressure and extreme aggression. He
believes that others invoke him to become aggressive because of his aggression, his
family side-line him and has every little contact with his other family members. He didn’t
attempt any suicide. The client was a drug addict. He used to take Chars, alcohol and
tobacco. He describes that whenever he feel alone, he used to do smoking and sometimes
take chars also.

Past Psychiatric History:

There is no past psychiatric history of client.

Past Medical History:

High blood pressure

Family History:

● Father: A. R

● Mother: S

● Siblings: 2 brothers and 2 sisters. One sister is married.

● Socio-Economic Status family: Poor

● History of Psychiatric Illness:

Client’s grandmother’s mother was not mentally healthy. She had some mental issues
which was not diagnosable at that time.

Personal History:

● Birth Injury: NO

● Childhood Disease: NO

● Developmental Milestones: Reached at appropriate age.

● Schooling :

⮚ Starting Age: 8 years

⮚ Achievements: NONE

● Puberty at the age of: At appropriate age.

● Sexual Abuse: NO

● Marriage
⮚ Age: 27

⮚ Arranged/ love: Arranged marriage.

⮚ Children: ONE

● Drug abuse: Yes

11

Premorbid personality:

● Relationship with

⮚ Family: Good and friendly.

⮚ Peers: Friendly.

Present mental state examination:

● Appearance & Behaviour:

Client was wearing dark blue colour shalwar kameez, his dress was neat and clean.
Moreover, he was wearing Sindhi cap. He was having proper hygiene. The
client’s posture size was normal having height almost 5’7 with broad shoulders.
He was sitting on bed like normal human beings sit. His expressions indicate
sustained emotional state.
● Speech: He was in between in the quality of speech. The rate of his speech was
slow. His voice was loud and clear.
● Orientation in time, place & person: He was aware of the place and person but
not of time.

Treatment:
Treatment is a long-term process that involves multiple interventions and regular
monitoring. There is a variety of evidence-based approaches to treating addiction. Drug
treatment can include behavioural therapy, medications or their combination.

● Medications:
Treatment medications such as methadone, buprenorphine are available for individuals
addicted to tobacco. Treatments for prescription drug abuse tend to be similar to
those for illicit drug that affect the same brain systems. For example,
buprenorphine used to treat heroin addiction. They can be treated with
behavioural therapies as there are not yet medications for treating addiction to
these types of drugs.
● Behavioural therapies:
Behavioural 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. Behavioural therapies
can also help people improve communication, relationship and parenting skills as
well as family dynamics.

Formulation of Case:
Drug addiction cause marked distress and significantly interfere with the person’s normal
routine. Client’s marital and social life suffered badly due to addiction. He become
outcast because of his behaviour. His use to sleep most of the time and his appetite is
increased.
Case No. 03

Post-Traumatic Stress Disorder

12
Summary
M. T is a 19 years old boy. He is experiencing irritable mood and started sleep-walking.
He is diagnosed as patient of Post-traumatic stress disorder. He belongs to upper class
family. He has 3 siblings (brothers). His parents are alive. He is single. He had
experienced sexual abuse in hostel four years ago. There is uncertainly in his behavior
and sometimes he is speaking with himself.
13

Introduction
Post-traumatic stress disorder (PTSD) is a disorder that develops in some people who
have experienced a shocking, scary or dangerous event. It is natural to feel afraid during
and after a traumatic situation. Fear triggers many split-second changes in the body to
help defend against danger or to avoid it. This “fight-or-flight” response is a typical
reaction meant to protect a person from harm. Nearly everyone will experience a range of
reactions after trauma yet most people recover from initial symptoms naturally. Those
who continue to experience problems may be diagnosed with PTSD. People who have
PTSD may feel stressed or frightened, even when they are not in danger.

Its symptoms include:

Re-experiencing symptoms include:

● Flashbacks

● Bad dreams

● Frightening thoughts

Avoidance symptoms include:

● Stating away from places, events or objects that are reminders of the traumatic
experience
● Avoiding thoughts or feelings related to the traumatic event.

Arousal and reactivity symptoms include:

● Being easily startled

● Feeing tense

● Having difficulty sleeping

● Having angry outbursts

Cognition and mood symptoms include:

● Trouble remembering key features of the traumatic event

● Negative thoughts about oneself or the world

● Distorted feelings like guilt or blame

● Loss of interest in enjoyable activities

14Sidra BibiDiagnosticCriteria

A. Exposure to actual or threatened death, serious injury or sexual violence in one (or
more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic(s) occurred to a close family member or close
friend.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic
event(s).
B. Presence of one (or more) of the following intrusion symptoms associated with
the traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary and intrusive distressing memories of the traumatic
event(s)
2. Recurrent distressing dreams in which the content and/or affect of the dream
are related to the traumatic event(s).
3. Intense or prolonged psychological distress at exposure to internal or external
cues that symbolize or resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning
after the traumatic event(s) occurred as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts or feeling
about or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders that arouse distressing
memories, thoughts or feelings about or closely associated with the traumatic
event(s).
D. Negative alterations in cognitions and mood associated with traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as evidenced by two
(or more) of the following:
1. Inability to remember an important aspect of the traumatic event(s)
2. Persistent and exaggerated beliefs or expectations about oneself, others or the
world.
3. Persistent negative emotional state.
4. Feelings of detachment from others.
5. Persistent inability to experience positive emotions.
E. Marked alterations in arousal and reactivity associated with the traumatic
event(s), beginning or worsening after the traumatic event(s) occurred as
evidenced by two (or more) of the following:
1. Irritable behaviour and angry outbursts typically expressed as verbal or
physical aggression toward people or objects.
2. Reckless or self-destructive behaviour.
3. Exaggerated startle response
4. Problems with concentration
5. Sleep disturbance.
15
F. Duration of the disturbance ( Criteria B, C, D and E) is more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social,
occupational or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance or
another medical condition.

Differential Diagnosis:
Acute stress disorder:

Acute stress disorder is distinguished from PTSD because the symptom pattern in acute
stress disorder is restricted to a duration of 3 days to 1 month following exposure to the
traumatic event.

Major depressive disorder:

Major depressive may or may not be preceded by a traumatic event and should be
diagnosed if other PTSD symptoms are absent. Specifically, major depressive disorder
does not include any PTSD Criterion B or C symptoms. Nor does it include a number of
symptoms from PTSD Criterion D or E.

Personality disorder:
Interpersonal difficulties that had their onset or were greatly exacerbated after exposure
to a traumatic event may be an indication of PTSD rather than a personality disorder; in
which such difficulties would be expected independently of any traumatic exposure.

Psychotic disorder:

Flashbacks in PTSD must be distinguished from illusions, hallucinations and other

perceptual disturbances that may occur in schizophrenia, brief psychotic disorder and
other psychotic disorders; depressive and bipolar disorders with psychotic features;
delirium, substance/medication-induced disorders and psychotic disorders due to another
medical condition.

Bio-Data
Name: M.T

Age: 19

Gender: Male

No. Of Siblings: 3 brothers

Birth Order: 4th

Education: FSc (continuing)

16

Marital status: Single

Source of Referral:
The client is referred by Dr. Akhtar CH. From SDK, Punjab.

Reason of Presentation:
Tension, threat to his life

Informant:
Father

Presenting Complaints:
The client’s behavior started to become odd. He started sleep-walking. He used to punch
in the air. Moreover, he started saying that someone is going to kill him. He can’t sleep at
night. He do not like to go to public places.
History of Presenting Illness:
In 2015, the client completed his FSc from Iqra college and went to Faisalabad for
engineering. After one month, his father received a call from hostel, informing about his
son that he has locked himself in a room and he is not opening the room. When his father
arrived at the hostel, he came to know that his son was sexually abused by the university
boys. Client come back to his home town and recovered. After a year, he again went to
Islamabad to study and again he was sexually abused. He came back but his behavior is
not the same yet he is non-aggressive. He used scream in nights, he is getting enough
sleep, his appetite is lost.

Past Psychiatric History:

There is no past psychiatric history of client.

Past Medical History:

There is no past medical history of client.

Family History:

● Father : M.I

● Mother: R

● Siblings: 3 brothers

● Socio-Economic Status: Upper

● Family History of Psychiatric Illness: NONE

17

Personal History:

● Birth Injury: No

● Childhood Disease: Measles

● Developmental Milestones: Reached at appropriate age.

● Schooling:
⮚ Starting Age: 4 years old

⮚ Achievements: Position holder till 9th class.

● Behaviour relations with

⮚ Peers: Friendly

⮚ Teachers: Obedient

● Puberty at the age of: Reached at appropriate age.

● Sexual Abuse: Yes

● Marriage: No

● Drug abuse: No

Premorbid personality:

● Relationship with

⮚ Family: Respectful and friendly.

⮚ Peers: Friendly

Present mental state examination:

● Appearance & Behaviour:

The client was wearing light blue shalwar kameez. His dress was neat n clean. He was
aware of his hygiene. His hair were properly combed. He was cooperative, he
answered all the questions very calmly.
● Speech: He was either talkative or mute. The pitch of his sound was
understandable. His words were clear.
● Orientation in time, place & person: He was aware of his surroundings i.e.
place and the people around him.

Treatment:
Post-traumatic stress disorder treatment can help you regain a sense of control over your
life. The primary treatment is psychotherapy but can also include medication. Combining
these treatments can help improve your symptoms.

● Psychotherapy:
Several types o psychotherapy also called talk therapy may be used to treat children and
adults with PTSD. Some types of psychotherapy used in PTSD treatment include:

18

⮚ Cognitive therapy:
This type of talk therapy helps you recognize the ways of thinking that are
keeping you stuck – for example, negative beliefs about yourself and the
risk of traumatic things happening again. For PTSD, cognitive therapy
often is used along with exposure.
⮚ Exposure therapy:
This behavioural therapy helps you safely face both situations and memories that
you find frightening so that you learn to cope with them effectively.
Exposure therapy can be particularly helpful for flashbacks and
nightmares.
● Medications:
Several types of medications can help improve symptoms of PTSD:
⮚ Antidepressants:
These medications can help symptoms of depression and anxiety. They can also
help improve sleep problems and concentration.
⮚ Anti-anxiety medications:
These drugs can relieve severe anxiety and related problems. Some anti-anxiety
medications have the potential for abuse, so they are generally used only
for a short time.

Formulation of Case:
PTSD cause marked distress and significantly interfere with the person’s academic life.
Patient’s social life suffered badly due to his illness. The person does not recognize that
his thoughts are unreasonable. Be become hopeless most of the time. His appetite and
sleep patterns are disturbed to his illness.
Case No. 04

Attention Deficit-Hyperactivity Disorder

19

Summary
M.A is a 12 year old boy. He is experiencing hyperactivity in his behavior. He is
diagnosed as patient of ADHD. He belongs to a upper class family. He is in 7th grade. He
has 3 siblings. His parents are alive. He was showing impulsivity in his behavior since 3
– 4 months. He has concentration problem. During the conversation, he was continuously
moving his hands and feet. He was well dressed. He was hyperactive.
20

Introduction
ADHD stands for Attention-deficit hyperactivity disorder. It is a medical condition. A
person with ADHD has differences in brain development and brain activity that affect
attention, the ability to sit still and self-control. ADHD can affect a child at school, at
home and in friendships. Kids with ADHD may have signs from one, two or all three of
these categories:
● Inattentive: kids who are inattentive have trouble focusing their attention,
concentration and staying on task. They may not listen well to directions, may
miss important details and may not finish what they start. They may daydream or
dawdle too much. They may seem absent-minded or forgetful and lose track of
their things.
● Hyperactive: kids who are hyperactive are fidgety, restless and easily bored.
They may have trouble sitting still or staying quiet when needed. They may rush
through things and make careless mistakes. They may climb, jump or roughhouse
when they shouldn’t. Without meaning to, they may act in ways that disrupt
others.
● Impulsive: kids who are impulsive act too quickly before thinking. They often
interrupt, might push or grab and find it hard to wait. They may do things without
asking for permission, take things that aren’t theirs or act in ways that are risky.
They may have emotional reactions that seem too intense for the situation.

Diagnostic Criteria:
A. A persistent pattern of inattention and /or hyperactivity-impulsivity that interferes
with functioning or development as characterized by (1) and/or (2):
1. Inattention: Six (or more) of the following symptoms have persisted for at
least 6 months to a degree that is inconsistent with developmental level and
that negatively impacts directly on social and academic/occupational
activities:
a. Often fails to give close attention to details or marks careless mistakes in
schoolwork, at work or during other activities.
b. Often has difficulty sustaining attention in tasks or play activities.
c. Often does not seem to listen when spoken to directly.
d. Often does not follow through on instructions and fails to finish
schoolwork, chores or duties in the workplace.
e. Often has difficulty organizing tasks and activities.
f. Often avoids, dislikes or is reluctant to engage in tasks that require
sustained mental efforts.
g. Often loses things necessary for tasks or activities.
h. Is often easily distracted by extraneous stimuli.
i. Is often forgetful in daily activities.
2. Hyperactivity and impulsivity: Six (or more)of the following symptoms
have persisted for at least 6 months to a degree that is inconsistent with
developmental level and that negatively impacts directly on social and
academic/occupational activities:
21
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected.
c. Often runs about or climbs in situations where it is inappropriate.
d. Often unable to play or engage in leisure activities quietly.
e. Often talks excessively.
f. Often blurts out an answer before a question has been completed.
g. Often has difficulty waiting his or her turn.
h. Often interrupts or intrudes on others.
B. Several inattentive or hyperactivity-impulsive symptoms were present prior to
age 12 years.
C. Several inattentive or hyperactivity-impulsive symptoms are present in two or
more settings.
D. There is a clear evidence that the symptoms interfere with or reduce the quality
of social, academic or occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or
another psychotic disorder and are not better explained by another mental
disorder.

Differential diagnosis
Autism spectrum disorder:

Individuals with ADHD and those with autism spectrum disorder exhibit inattention,
social dysfunction and difficult-to-manage behavior. Children with autism spectrum
disorder may display tantrums because of an inability to tolerate a change from their
expected course of events.

Reactive attachment disorder:

Children with reactive attachment disorder may show social disinhibition but not the full
ADHD symptoms cluster and display other features such as a lack of enduring
relationships that are not characteristic of ADHD.

Anxiety disorders:

ADHD shares symptoms of inattention with anxiety disorders. Individuals with ADHD
are inattentive because of their attraction to external stimuli, new activities or
preoccupation with enjoyable activities.

Depressive disorder:
Individuals with depressive disorders may present with inability to concentrate. However,
poor concentration in mood disorders becomes prominent only during a depressive
episode.

22

Bio-Data
Name: M.A

Age: 12

Gender: Male

No. Of Siblings: 3

Birth Order: 1st

Education: 7th grade

Marital status: single

Source of Referral:
Through OPD

Reason of Presentation:
Misbehaviour in school

Informant:
Mother

Presenting Complaints:
The client is misbehaving with the peer group in school, siblings, teachers . He is feeling
difficulty in concentrating on homework and other activities. He doesn’t like to play with
his age fellows. He doesn’t like to go to school. Usually he is suffering from fever.

History of Presenting Illness:

Almost an year ago, the client’s mother observed that her child is not performing well in
school. He is not interacting with his peer group. Moreover, he is not taking interest in his
school work and other activities. He is forgetting his daily routines. His teachers are
complaining about his misbehavior in class and lack of concentration

Past Psychiatric History:

There is no past psychiatric history of client.

Past Medical History:

There is no past medical history of client.

23

Family History:

● Father: M.A

● Mother: Mrs. A. A

● Siblings: Three

● Socio-Economic Status: Upper class

● Family History of Psychiatric Illness: NONE

Personal History:

● Birth Injury: No

● Childhood Disease: He had Measles when he was 9 years old.

● Developmental Milestones:
A. started crawling when he was 6 months old baby. At the age of 9 months, A. said his
first word ‘BABA’. When he was 1.5 years old, he started walking.
● Schooling:

⮚ Starting age: 3 years old

⮚ Achievements: He got his 1st position when he was in 3rd grade. He has
maintained his position afterwards.
● Behaviour Relations with:

⮚ Peers: Very friendly and playful

⮚ Teachers: Has always show respectable behaviour.

● Sexual abuse: NO

● Drug Abuse: NO

Premorbid Personality:

● Relationship with

⮚ Family: Very friendly

⮚ Peers: Very playful

● Usual mood: Normal

● Fantasies: He is not living in any fantasy world.

Present Mental State Examination:

● Appearance and Behaviour:

A. was wearing red check shirt with blue jeans and white sneakers. His dress was neat
and clean. His hair were properly brushed. His hands and feet’s nails were also
cut. He was well aware of his hygiene. While talking, he continuously moved his
both legs.
● Speech:
His words were clear. The pitch of his sound was loud n clear.

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● Orientation in Time, Place and Person:

He was fully orientated to the time, place and the surroundings.
● Attention and Concentration:
He was paying his full attention on the conversation which therapies and his mother was
having.
Treatment:
Treatment for ADHD usually includes:

● Medicine: this activates the brain’s ability to pay attention, slow down and use
more self-control.
● Behaviour therapy: therapists can help kids develop the social, emotional and
planning skills that are lagging with ADHD.
● Parent coaching: through coaching, parents learn the best ways to respond to
behaviour difficulties that are part of ADHD.
● School support: teachers can help kids with ADHD do well and enjoy school
more.

The right treatment helps ADHD improve. Parents and teachers can teach younger kids to
get better at managing their attention, behavior and emotions. As they grow older, kids
should learn to improve their own attention and self-control.

Formulation of Case:
ADHD cause marked distress and significantly interfere with the person’s academic
functioning. Patient’s social life suffered badly due to his illness. He usually made
common mistakes in his daily routine. He sometimes showed aggressive behavior at
school and in home. His appetite and sleep patterns are also effect due to his illness.
Case No. 05

Cannabis Withdrawal
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Summary
K is a 28 years old man. He is a drug addict patient showing withdrawal symptoms. He
belongs to poor class family. He is Hafiz-e-Quran. He has 6 siblings, 3 brothers and 3
sisters. His parents are alive. He is married. He has four children (2 sons and 2
daughters). His wife is a maid. He had his own shop. He loved his wife and children and
show great affection and care for his family. He was well dressed. He was cooperative
and was not showing aggressive behavior.
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Withdrawal symptoms occurs when a person who is dependent on a drug suddenly stops
taking it. People who repeatedly use certain drugs often get withdrawal symptoms when
they quit because their brains and bodies adapt, or ‘get used to’, having the drug. If the
drug is suddenly removed, the user may experience withdrawal symptoms until the brain
and body have time to re-adjust to the new, drug-free state – a process that normally will
take place over several days or weeks.

Withdrawal symptoms are different depending on which drug is involved. It has been
debated for several years whether or not marijuana can cause withdrawal symptoms in
heavy users who stop taking the drug. However, in 2013, the American Psychiatric
Association definitively included cannabis withdrawal in the Diagnostic and Statistical
Manual of Mental Disorders (DSM), a handbook used by US healthcare professionals
that lists all medically recognized mental disorders.

Some factors that may affect cannabis withdrawal include:

● Severity of dependence or addiction

● Amount of use.

● Length of use.

● Co-occurring medical conditions.

● Abuse of other drugs.

Withdrawal also tends to be more severe among adults, possibly because they use more
often and in higher amounts. In addition, withdrawing from tobacco and chars at the same
time can be more severe than coming off of either substance alone.

Diagnostic Criteria:

A. Cessation of cannabis use that been heavy and prolonged (i.e., usually daily or
almost daily use over a period of at least a few months).
B. Three (or more) of the following signs and symptoms develop within
approximately 1 week after Criterion A.
1. Irritability, anger or aggression.
2. Nervousness or anxiety
3. Sleep difficulty (e.g., insomnia, disturbing dreams).
4. Decreased appetite or weight loss.
5. Restlessness
6. Depressed mood
7. At least one of the following physical symptoms causing significant
discomfort: abdominal pain, shakiness/ tremors, sweating, fever, chills or
headache.
C. The signs or symptoms in Criterion B cause clinically significant distress or
impairment in social, occupational or other important areas of functioning.
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D. The signs or symptoms are not attributable to another medical condition and are
not better explained by another mental disorder including intoxication or
withdrawal from another substance.

Differential Diagnosis:
Because many of the symptoms of cannabis withdrawal are also symptoms of other
substance withdrawal syndromes or of depressive or bipolar disorders, careful evaluation
should focus on ensuring that the symptoms are not better explained by cessation from
another substance (e.g., tobacco or alcohol withdrawal), another mental disorder
(generalized anxiety disorder, major depressive disorder) or another medical condition.

Bio-Data
Name: K. S

Age: 28 years old.

Gender: Male

No. Of Siblings: 6 (3 brothers, 3 sisters)

Birth Order: 2nd number.

Education: Hafiz-e-Quran

Marital status: Married

Source of Referral:
The client has been referred from OPD.

Reason of Presentation:
Abdominal pain, high fever

Informant:
Himself.

Presenting Complaints:
He was suffering from abdominal pain from almost one week and extreme weakness.
Even he can’t stand or walk. Recently, he had vomiting and also suffering diarrhea and
fatigue. He used to get irritated easily over small things. He also had sleep difficulty. He
had lost his appetite as well.

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History of Presenting Illness:

Client describes that he was suffering fatigue and extreme weakness that he could barely
stand or walk. The client further tell that he is a drug addict and using chars from almost
6 years, heroine from 5 years and cigarette from 6 years. This condition of client is,
because the client has stopped the intake of all these substance and want to live a normal
life. He has been suffering from this condition from almost 5-6 days, when he stopped the
intake.

Past Psychiatric History:

There is no past psychiatric history of client

Past Medical History:

There is no past medical history of client.

Family History:

● Father : M.S

● Mother: Z

● Siblings: 2 brothers and 3 sisters

● Socio-Economic Status family: Poor

● History of Psychiatric Illness: NILL.

Personal History:

● Birth Injury: NO

● Childhood Disease: NO

● Developmental Milestones: Reached at appropriate age.

● Schooling:

⮚ Starting Age: 6 years old.

⮚ Achievements: Become Hafiz-e-Quran at the age of 12.

⮚ Behaviour relations with

✔ Peers: Good

✔ Teachers: Good.

● Puberty at the age of: At appropriate age.

● Sexual Abuse: NO

● Marriage

⮚ Age: 21

⮚ Arranged/ love: Arranged marriage.

⮚ Children: Four.

● Drug abuse: Yes

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Premorbid personality:
● Relationship with

⮚ Family: Good

⮚ Peers: Friendly

Present mental state examination:

● Appearance & Behaviour:

Client was light skin colour shalwar kameez. His dress was neat and clean. Hair were
properly trimmed. His hands and feet’s nails were also cut. But this feet’s were
covered with mud. The overall appearance of the patient was pleasant. The
behaviour of the client was also clam and friendly. He answered all the questions
properly. The patient posture size was normal having height almost 5’6 with
normal shoulder size. His sitting posture was also normal. His expression was
normal.
● Speech:
He was in between in the quality of speech. The rate of his speech was slow. His voice
was clear.
● Orientation in time, place & person:
He was aware of the place and person but not of time.

Treatment:
Long-term users of hash typically experience hash withdrawal symptoms, including
insomnia, anxiety, irritability, depressed mood and loss of appetite. Symptoms can be felt
within 24-72 hours of quitting. They tend to become more intense over the course of the
first week and begin to fade after about 2 weeks.

Behavioral therapies and medications any help to relieve symptoms and improve the
likelihood recovery.

● Cognitive-behavioural therapy or CBT, has shown efficacy in marijuana

dependence. A therapist teaches a recovering user on how to become more aware
and in control of behaviours that can lead to drug use.
● Contingency management has also been used to promote marijuana and hash
abstinence. In this treatment approach, the hash or marijuana user receives
vouchers for services and goods as incentives for remaining drug-free. The
vouchers are given, for example, after the person passes a urine test and is found
to be drug-free.
● No medication are used exclusively for hash withdrawal treatment. But medical
professionals may prescribe medications manage symptoms such as anxiety,
insomnia, headaches and depression

Since hash withdrawal is not usually fatal or associated with medical complications,
users may be able to detox at home or in an outpatient detox program. Outpatient
programs

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allow users to live at home and attend treatment a few days a week for a few hours at
a time.

Those who are considering outpatient or home detox should be aware, however, that
spending time in the same environments where hash use took place increases the risk
of relapse. For those at high risk of relapse who abuse other drugs, and who have
mental health disorders, inpatient may be a better choice.

Formulation of Case:
Cannabis withdrawal cause marked distress and significantly interfere with the person’s
normal routine. Patient’s marital and social life suffered badly due to addiction. He had
sleep difficulties and he feel that his appetite is decreased. He is feeling fatigue all the
time.
Appendix A