CASE REPORTS-II

Submitted By:

Name (SAP ID)

Class: BS Psychology
Semester: 8th
Date:
Submitted to:

Subject Teacher

Department of Applied Psychology

Faculty of Social Sciences and Humanities

Riphah International University, Islamabad

Fall, 2021
 Table of Content

Tittle Pg.

No

Case 1: Neurosis

Severe Depression with Recurrent Episodes 01

Case 2: Psychosis

Schizoaffective Disorder (Depressive Type) 17

Case 3: Child Case

Attention Deficit Hyperactivity Disorder 37

Case 4: Drug Addiction

Alcohol Use Disorder 48

Protocols of All 4 Cases 61

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Case # 1

296.33 (F33.2)

Major Depression Disorder

Recurrent Episodes

With Severe Symptoms

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Summary

N.T is 20 years old girl. She contacted through Facebook due to presenting psychological

complaints. 2 sessions were conducted via Zoom as she is currently residing in Lucknow, India.

As she has good insight of her psychological issues, she contacted via internet due to presenting

complaints of low mood, low self-worth, lack of confidence, lack of concentration, loss of

interest, sexual orientation issue and negative thoughts. She was assessed using informal as well

as formal assessment including behavior checklist, clinical interview and subjective rating of

presenting complaints while for formal assessment House Tree Person and Beck Depression

Inventory were administered. She did Score 38 in BDI which manifests severe depression

Cognitive Behavior Therapy, Meditation, Relaxing Techniques, Good Nutrition and Exercise

was recommended as management plan.

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Identifying Data:

Name: N.T.

Age: 20

Gender: Female

Siblings: 04

Birth Order: 03

Education: B.A

Occupation: Teaching

Marital Status: Unmarried

Address: Lucknow

Informant: Herself

Reason and Source of Referral:

The girl herself contacted through Facebook for assessment of her psychological disturbance due

to personal reluctance to visit psychiatrist or a psychologist physically because of societal taboos

of visiting a psychologist. She contacted due to her low mood issues, lack of concentration,

sexual orientation and loss of interest in everything.

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Presenting Complaints:

Complaints Frequency Intensity Duration

Anhedonia Many times a day Severe 1 Year

Suicidal ideation once a day Moderate 2 years

Isolation 15 hours a day Severe 3 year

Irritability All the day Severe 2 year

Worthlessness Many times a day Severe 2 years

Hopelessness Many times a day Severe 3 years

Fatigue 10 hours a day Moderate 1.5 Years

Crying spells Many times a day Severe 2 Years

Behavioral Observation:

N.T. appeared neat and tidy in a casual shirt and hijab on head. Her body posture was not normal

and her shoulders were bent. She sat with her hands in lap while fidgeting the fingers. She

maintained eye contact but felt hesitant to maintain it upon few questions. She was cooperative

but she felt difficult to speak her thoughts. Her mood was low and there was a sad expression on

her face continuously.

History of Present Illness

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The patient contacted through Facebook due to low mood, suicidal ideation, sleeplessness, lack

of concentration, weight lost due to lack of appetite and anhedoni. According to the client, her

issue started in her childhood when she was discriminated by her parents and her brother was

prioritized over her. She reported that she never enjoyed a complete feeling of happiness. During

childhood, at the age of 6 she was sexually abused for 1 st time by an uncle of her family while

she was again abused at age of 8 by a stranger in a street. Due to which she started hating men.

She started school at the age of 5. She was not good in studies so she never liked school. She

reported a conflicted relationship with teachers due to her never completing the home work. She

had difficult time completing her studies. During college life she has a friend. She realized that

she is physically attracted to girls instead of boys with whom she had trust issues and feeling of

hatred for them. After Bachelor’s (B.A), she quitted studies because of her disinterest an being

confused about what to study because she had no interest as well as guidelines.

She started a job at a private school. Her relationship with colleagues was constrained and she

did not like talking to anyone. She reported that she is not happy with her job and she might quit

it because of societal demands of expression and friendliness. She reported that she faced

extreme disturbance in maintain her prayers’ routine and she will rate her religiosity 2 on a rating

scale of 10. She told that she tried but she could not firm her connection with God.

She never visited psychiatrist due to fear of society and being made fun of. She contacted for

help due to her mood getting so low every day. She reported that she never get anyone at school

or at family who could help her find solution for her issues. She reported that she was ridiculed

by family for her psychological issues. She wanted to stay alone because she didn’t like dressing

and makeup for events so she preferred staying at home.

Background Information
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Personal History

Birth and Early History: The client is 3rd among siblings in birth order and is 1 year older than

her brother. Due to immediate birth of brother. She reported that she was never loved. She born

through normal delivery and her weight at time of birth was 2KG. She was underweight and was

kept in nursery to a week under supervision. Her first cry was time appropriate. Her physical

health throughout the childhood suffered due to recurrent diseases due to weak immunity.

Education History

The schooling of client started at the age of 5 in a government school. She was an average

student and had extreme difficulties in mathematics throughout her education. She didn’t make

any friends except one friend in college with whom her bond broken later due to her extreme

attachment to her that led to fights over minor things and so much expectations of the client from

one she likes e.g. talking to nobody else or it would hurt her. After 14 years bachelor’s

education, the client couldn’t continue her education because she could never decide what she

wants to do next. She although wants to resume her studies but does not have any motivation as

well as her indecisiveness is a hurdle in the way to decide anything.

Sexual History

She reached puberty at the age of 12. Her source of sexual information was internet. She reports

extreme hatred toward men and she reported her disinterest in getting married to any man

because of her hate for them as well as her sexual inclination towards females. As she reported a

sexual abuse twice in childhood, she have extreme trust issues for males and finds no interest in

them. She was molested and harassed as a child so she had extreme feeling of hatred for men.
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Family History

The girl belongs to a middle class, Muslim family. Her father is 55 years old and works in a

private office while her mother is 50 and is a house wife. Her relationship with both parent is not

so good. There is a big communication gap between her and parents. Her relationship is

particularly conflicted with her mother who always asked her to stay silent when she tried to

speak for her issues because she said that these issues are unreal and does not exist. Her father

shows little or no interest in her matters of other siblings. He only pays attention to his son and

talks only to him. The family is nuclear but there is interference of paternal family in personal

life matters. She is compared with other cousins and girls of her age at very gathering that she

does not anymore likes to attend any of them and prefers isolation.

Father is authoritative figure of the house. He is so inaccessible to communicate that client

reported starting a job to not ask him for money for her financial needs. Client’s father

relationship with mother is also not good and he often insults her for minor reasons.

Drug Abuse

The patient reported no drug abuse.

Forensic History

The patient reported no forensic history.

Past Medical & Psychiatric Illness

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The patient reported medical issue of extreme itching in skin during past one year for which she

is taking medicines. Her stomach is often disturbed and she has stomach burning and nausea

issues. There is no psychiatric issues diagnosed before.

Pre-morbid Personality

Upon asking her pre-morbid personality, she said that when I look back into the past it seems

like I was always the same, a girl who preferred isolation, who feared to take part in social

activities someone who never liked getting ready to go to events because that requires dressing

up and makeup because nobody accepts you with your real face so I prefer staying at the home.

Even as a child, she reported lack of happiness and enjoyment in childhood. She said that I never

liked my family or household and I do not like to ask from them for anything that is why I started

earning for my own self. She never made friends and she reported her extreme sensitive nature

because she get hurt by people’s minor actions since her childhood, it although got intense

during teenage.

Psychological Assessment

Psychological assessment was done at both formal and informal levels.

Informal Assessment

 Clinical Interview

 Behavioral Observations

 Subjective Ratings

I) Clinical Interview:
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To determine the predisposing factors that caused the psychological presenting

complaints in the clients, a clinical interview was conducted. As this interview included so much

sensitive information to client’s mind, it was completed with 2 breaks in 3 hours. The interview

revealed so much information about childhood abuse, family issues, strained housed

environment, lack of support, discrimination between siblings and comparison with others.

II) Behavioral Observation

Behavioral observation is a primary technique to decipher non-verbal cues through body

language and expressions of the client during the interview. Her vocalization, verbalization,

facial expressions, temperament and general appearance was observed/

The client is 20 year old with 5.3 feet height and 38 KG weight that is extremely low

according to Body Mass Index. She had a sad face and nervous feeling as depicted though

continuous pressing of fingers. She was neatly dressed and she cooperated during interview with

little reluctance in disclosing information. Her level of comprehension was good but she lacked

words to put her thoughts into words. He body gesture was not normal and she was sitting with

bet shoulder with her hands in laps while pressing the fingers. Her orientation of time, place and

person was intact and she had good insight of her psychological issues that she herself wanted to

amend them.

III) Subjective Ratings of Presenting Complains

Intensity of the presenting problems was assessed on 0-10 point scale that targeted the

severity of the problem. Subjective rating of the scale was done by the client herself to

present the intensity of the problems.

Table 1.1 Patient’s subjective ratings of presenting complaints as reported by the patient
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Problematic Area Subjective Rating by the Patient

Low mood 10

Anhedonia 09

Suicidal Ideation 07

Isolation 10

Irritability 10

Fatigue 08

Fear 10

Negative thoughts 09

Aggressiveness 10

Formal Assessment

For the formal assessment of the client following test were used;

 Beck Depression Inventory

 House Tree Person

I) Beck Depression Inventory (BDI)

BDI (Beck et al, 1979) is a 21 items scale that assesses the level of depression including

cognitive, affective, somatic, behavioral and motivational aspects as well as suicidal intentions.
 11

Because the presenting complaints of the client matched the corresponding items of the scales, it

was used.

Table 1.2 Beck Depression Inventory Results

Raw Scores Category of Depression

38 Severe Depression

Qualitative Analysis:

The client scored 38 on BDI which depicts severe depression.

II) House Tree Person (HTP)

HTP was administered on client to get a detailed picture of client’s personality. Client

drew a small house that shows her detachment from family. There are no windows that depicts

her unwelcoming attitude. Closed door shows restrictions. Presence of sun shows presence of an

authoritative person in life. Absence of chimney shows repressed instincts. Shatter shows

extreme withdrawal. Client drew a triangle headed tree showing her aggressiveness and feeling

of insignificance. The tree have small branches showing her dissatisfaction from society. A small

stem shows her stunned inner growth. Trunk width is normal that means her personality is

flexible. Absence of leaves shows lack of growth and functionality in society. There are no roots

showing lack of security. Client drew a person with small head showing intellectual issues. Arms

are closed showing unwelcoming attitude. Small feet show dependency. Shirt button shows

maternal dependency and immaturity.

Case formulation
 12

N.T. is a 20 year old girl who has contacted due to presenting psychological complaints

including loss of interest, low mood, fatigue, sleeplessness, weight loss and loss of appetite. For

diagnosing the client, she was assessed using formal and informal assessment. That points

towards Major Depressive Disorder Recurrent Episode 296.33 (F33.2).

Matching the complaints of the client with the DSM-5 criteria of corresponding complaints also

points towards the same diagnose including Anhedonia, insomnia, fatigue, worthlessness,

isolation and suicidal ideation. These symptoms are significant to cause significant distress and

impairment in social, occupational and family life of the client. There are no episodes of mania o

hypomania. Also, this episode is not an effect of any medication or bereavement.

According to APA depression affects 1 in 15 adults every year that is 6.7% of it. It onset of

appearance can range from late teens to early 20s with females being more prone to it. If there is

genetic history of depression in first degree relatives, there is 40% heritability chance (APA).

Depression is although different from bereavement that is a natural response to a sad event in

life. There can be many reason of depression including disturbed neurochemistry, genetics,

personality type and environmental factors. The chances of recovery from depression are 80% to

90%. Symptoms stop appearing after a considerable time period of treatment that includes

psychological and physical diagnose and then a relevant therapy. Sometimes blood test is also

conducted to see if there is any thyroid imbalance or vitamin deficiency that is causing

depression. Family history, medical history, environmental, cultural and childhood history are

explored to find the root cause to diagnose, treat and manage the issue. Low mood, fatigue, loss

of appetite, weight loss, muscular pain and sleep disturbance are symptoms of depression

(Kanter, 2008).
 13

Predisposing factors included childhood abuse, homosexuality and conflicted home environment.

Perpetuating factor was homosexuality and negative self-image.

As all these symptoms are evident in the client, the client is diagnosed with major depressive

disorder with severe symptoms on BDI scale.

Case Conceptualization

Biopsychosocial & Spiritual Model:

Lack of self worth

Negative childhood
experience
Low confidence
Distorted sexual
orientation
Isolation

Decreased Religiousity Poor Phsycial Health

Fluctuating spirtuality Underweight
-
Poor Appetite

Societal Expectations
Religious Obligation
No Friends
School life issues
Sexual Abuse
Household
Discrimination
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Diagnosis

Major Depressive Disorder with Recurrent Episodes 296.33 (F33.2) according to DSM

Criteria.

Management Plan

Following plan is made for the client to amend treat her present psychological complaints.

 Psychotherapy

 Cognitive behavior therapy (CBT)

 Interpersonal therapy (IPT)

 Mindfulness-based cognitive therapy (MBCT)

 Family psycho-education and counselling

Psychotherapy

Psychotherapy is also called talk-therapy in which a talking interaction takes between the

psychotherapist and the client. It provides a way to the client to express their inner feelings that

makes it easy for both the client and the therapist to find out the problematic point, causes and

ways to amendment.

Psychotherapy is recommended to the client because it will help the client to know her own

entangled thoughts making the thoughts organized and comprehendible. It also helps the

psychotherapist to know strengths and weaknesses of the client to better know the client and

implement a particular therapy.

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Cognitive behavior therapy (CBT)

CBT is one of most widely used therapy for changing negative thoughts’ pattern by using ABC

model. In this model affects are modified in such a way that behavior is molded in positive form

to bring positive consequences. As the client has negative thoughts about herself, it is important

to change her thinking pattern. Increased feeling of self-worth will provide motivation to work

better on the treatment plan. It will also help to seek positive lessons from negative events of the

life.

Interpersonal Therapy

It is an effective therapy for depressive people because it aims on helping them to interact better

with the people they are facing problems with. As the client is facing problems with the family,

communicating and interacting while ensuring own boundaries will help her.

Mindfulness-based cognitive therapy (MBCT)

It includes deliberatively paying attention to own thoughts. As knowing own thoughts in crucial

for higher EQ that helps in coping own problems and maintaining positive social relationship, it

is recommended as a treatment to client to reflect own thoughts.

Family Psycho-Education and Counselling

As the family of the client has conflicted relationship with the client, psycho-education of the

client’s family is also necessary because after all the therapies going back to the precipitating
 16

environment can trigger depression more so the psycho-education of the client’s family is also

necessary.

Suggestions

 Properly following the treatment plan for a significant period of time

 Avoiding the precipitating factors as much as possible

 Seeking positivity provoking sources e.g. reading

 Good nutrition and self-care

Prognosis

Positive Points in Prognosis

 Insight of the issue

 Will to amend

 Educated

 Understanding

Negative Points in Prognosis:

 Suicidal tendencies

 Deep rooted hopeless

 No family sport

 No peers
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 Lack of self-confidence and motivation

Case # 2

DSM-5 295.70 (F25.1)

Schizoaffective

Depressive Type
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Summary

B. U.is 29Years old lady. As I personally know her, she contacted me last year due to her

psychological issues. At that time, she had moderate depression. She again contacted this month

due to her symptoms getting intense. The client had intense feelings of low mood, lack of

pleasure, feeling of being abandoned by everyone she loves, auditory and tactile hallucinations,

delusions and disorganized speech. She was assessed using informal as well as formal

assessment including behavior checklist, clinical interview and subjective rating of presenting

complaints while for formal assessment Beck Depression Inventory, House Tree Person and

PANSS Scales were administered.

She scored 75 in PANSS which indicates moderate illness. She scored 41 in BDI

indicating severe Depression. For medication, client was referred to psychiatrist. Psycho-

education, therapies, life style rehabilitation, electroconvulsive therapy (in case that other things

do not work) and clinically suggested nutrition was recommended.

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Identifying Data

Name: B.U

Age: 29

Gender: Female

Siblings: 04

Birth Order: 01

Education: Masters

Occupation: Freelancer

Marital Status: Unmarried

Address: Rawalpindi

Informant: Herself

Reason and Source of Referral:

She contacted through personal number due to presenting complaints of low mood, fatigue,

insomnia, binge eating, loss of feelings, lack of interest in anything, isolation, hallucination,

delusions and disorganized speech. She was previously diagnosed with moderate depression

clinically but from last 7 months she was having hallucinations as well.
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Presenting Complaints

Complaints Frequency Intensity Duration

Hallucinations Once in 3 days Moderate 7 Months

Delusions Once in a day Moderate 9 Months

Suicidal ideation Twice or thrice a month Moderate 7 years

Isolation 18 hours a day Severe 1 year

Irritability All the day Severe 1 year

Worthlessness Twice a day Moderate 3 years

Hopelessness Many times a day Severe 3 years

Fatigue 15 hours a day Moderate 2 Years

Crying spells Twice a day Mild From 1 year

Behavioral Observation

B. U appeared in a casual night dress. Her hair was not properly done and she appeared sleepy.

Her body posture was not normal. Her shoulders were dropped. She was fidgeting her fingers

and biting the skin around her nails. She maintained eye contact but not throughout the session.

She rolled her eyes in a confused manner any times upon being asked a question. She appeared

dull and melancholy. Her speech was disorganized and she lacked words to describe her feelings

and inner state.

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History of Present Illness

The client has contacted through mutual friends last year when she was diagnosed with

depression. The client had complained low mood, fatigue, insomnia, emotional eating, negative

self-thoughts, insomnia and hallucinations. She visited 2 psychiatrist then but she was

disappointed. She reported that due to the prescribed medicines I slept for 18 hours a day and

could not prepared for my exams. When she visited another psychologist, she was disappointed

by his response. When she reported him her issues, he said that ‘this is life and you have to deal

with it’. She told me that ‘if this is life and I have to deal with it then why should I visit a

therapist?

The client is first born children of her parents. As a child, she did not enjoy much approximation

of mother because she was a working woman in government setup. Her father’s family fought

with her parents and they had to leave for a separate house. She reported that when she was 4

years old, she visited her grandfather’s house. When he saw her, he said that go upstairs to your

uncle, do not come to me because I do not want to see you. She said that I hate my paternal side

of the family because they left us with nothing, my parents worked hard for us.

As a child, the client was molested by her own uncle, brother of her father. She also reported that

as a teenager she was again abused by cousin of her father. She was sleeping and he jumped onto

her. She said that even today when I am sleeping, I wake up from that fear. I feel like someone is

rubbing my body and the feeling is so intense that I often take bath in extreme cold.

She was a bright student and had many friends at school. Some of her friends are still with her

and supported her throughout her every problem. She is good at socializing but it often drains her
 22

out of energy so she prefers isolation but this period of isolation has extended during last one

year.

The client loved her siblings but reported that what is allowed to her brothers was not allowed to

her. She said that she had dreams but due to fear of her parents she could never follow those

dreams. She reported that she loved a guy but she knew that her parents would never agree for

him so she did not tell her parents about him. That guy cheated on her with another girl who was

best friend of her. She started focusing on her career instead. As she knew her parents will never

allow an office job to her, she started freelancing. Due to continuous use of gadgets, she got

intense migraine so she quitted it for some time but it was her only feeling of accomplishment so

she again resumed it.

The client reported that she had already moved on in her life and was well adjusted even with

depression until last year when due to a big conflict between her paternal side of family and her,

she was misunderstood by her father. She was beaten by her father that she could not stand. She

was made to apologize her relatives. After that the client’s depression intensified and she started

feeling that there is some demon that is always following her. During the first month, after this

incident, she hallucinated almost for 3 weeks consecutively. Hallucination gradually decreased

as she kept herself busy but low mood and other symptoms including anhedonia and fatigue

persisted She reported that sometimes when she was sleeping, the door opened and someone fell

upon her. She also reported that she saw shadows moving and she smelled intense bad odors that

no one else did when she asked them. The client reported that the degree of sadness, low mood,

fatigue and negative thoughts is relatively more than the duration she hallucinated. She

hallucinated more frequently when she was idle. Due to this when she quitted freelancing and

started getting more hallucinations, she again resumed her work to get rid of this.
 23

The client kept a lot of pets. She reported that now she could not love them the way she once did.

They do not please her anymore like before. She was gradually losing interest in life and felt

hopeless. The client had trust issues and feared getting married. She had rejected many proposals

and due to her obesity, she felt that she was not loveable. She reported that people consider her

rich so they approach her otherwise no one truly loved her for who she really was.

Background Information

Personal History

Birth and Early History: The client was 1st among siblings in birth order. Her weight at the time

of birth was normal. First cry after birth was time appropriate. She was a healthy and active

child. She covered her development milestones age appropriately.

Education History

The schooling of client started at the age of 5 in an elite school at RWP. The client was a

good student and scored well in every subject until her A-levels where she failed in mathematics.

She had many friends and she liked socializing. She was a good student nonetheless with fair

grades, good friends and a good bond with teachers.

Sexual History

She reached puberty at the age of 14. Her source of sexual information was her friends.

She was sexually abused, molested twice in her childhood. Her sexual orientation is normal.

Family History

The client belonged to an upper middle class Muslim family. Her father was 60 years old

with no physical or psychological illness. Her mother was 55 years old with no psychological
 24

illness but with a physical disease of arthritis. The client reported that her mother was so

generous, cooperative and caring. According to the client her father was authoritative and

conservative. He allowed cline’s mother for the job because of circumstances but he never

allowed the client to work on her career due to his mentality that woman should stay at home.

Client’s father relationship with his wife was also strained. He always tried to please his family

and compelled his wife to be nicer to them as well. This made the environment of their house

often so suffocated that the client’s father did not talk to client’s mother for days.

He also used to beat the client in childhood and even in her adulthood just a year ago. It was after

this event that the client started hallucinating.

Drug Abuse

The patient reported smoking cigarettes rarely. There is no other drug intake reported.

Forensic History

The patient reported no forensic history.

Past Medical & Psychiatric Illness

The client has extreme obesity. She was also diagnosed with moderate depression a year ago.

Pre-morbid Personality

In childhood, client was a happy child. After sexual and physical abuse, she faced mood issues

but that were not so persistent like they were now. The client said that she liked socializing and

making friends. She was good in studies and wanted to be a successful woman. It was betrayal of

her boyfriend that caused her depression and then her father’s physical abuse, beating, that

caused her extreme disturbances including hallucinations.

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Psychological Assessment

Psychological assessment was done at both formal and informal levels.

Informal Assessment

 Clinical Interview

 Behavioral Observations

 Subjective Ratings

I) Clinical Interview

To get details about the deep causes of client’s condition, two interviews were conducted

for 2 hours each time. According to the interview client major issues were domestic

environment, sexual abuse, physical abuse, hurdles in pursuing career, breakup and feeling of

worthlessness.

II) Behavioral Observation

Behavioral observation is a primary technique to decipher non-verbal cues through body

language and expressions of the client during the interview. Her vocalization, verbalization,

facial expressions, temperament and general appearance was observed.

The client was 29 years old lady with 102 KG weight and 5.10 height. The client had

issues in speech and she also reported interrupted thoughts. Her comprehension of speech was

intact. Her orientation of time, place and date was also normal. She had insight of the issue but

her motivation to solve it was low sue to lack of trust i.e. lack of self-efficacy.
 26

III) Subjective Ratings of Presenting Complains

Intensity of the presenting problems was assessed on 0-10 point scale that targeted the

severity of the problem. Subjective rating of the scale was done by the client herself to present

the intensity of the problems.

Table 1.1 Patient’s subjective ratings of presenting complaints as reported by the patient

Problematic Area Subjective Rating by the Patient

Low mood 8

Anhedonia 09

Suicidal Ideation 06

Isolation 08

Irritability 10

Fatigue 07

Fear 05

Negative thoughts 08

Aggressiveness 10

Formal Assessment

For the formal assessment of the client following test were used;
 27

 Beck Depression Inventory

 Positive and Negative Syndrome Scale

 House Tree Person

I) Beck Depression Inventory (BDI)

BDI (Beck et al, 1979) is a 21 items scale that assesses the level of depression including

cognitive, affective, somatic, behavioral and motivational aspects as well as suicidal intentions.

Because the presenting complaints of the client matched the corresponding items of the scales, it

was used.

Table 1.2 Beck Depression Inventory Results

Raw Scores Category of Depression

41 Severe Depression

Qualitative Analysis:

The client scored 41on BDI which depicts severe depression.

II) Positive and Negative Syndrome Scale

PANSS was originally developed for measuring the symptoms of schizophrenia but it is

also used to measure symptoms change for bipolar and schizoaffective disorder (Ariana et al,

2017). The PANSS is 30 items scale. It consists of 3 subscales including positive scale, negative
 28

scale and general psychopathology scale. Scores for positive and negative scale range from 7 to

49 respectively while for general psychopathology scale the score range from 16 to 112. Higher

is the total score. According to Stefan Luecht and colleagues, 2005, different scores of PANSS

corresponds as follow;

 Mildly ill lower-58

 Moderately ill 59-75

 Markedly ill 76-95

 Severely ill 96-116

The test was administered to the client to measure the degree of psychotic symptoms. She

scored 75 in PANSS which shows moderate psychiatric illness.

Table 1.2 PANSS scoring of the client

Subscale Raw Scores

Scores 75

Category Severe Psychotic Symptoms

Qualitative Analysis:

The client scored 75 on PANSS that depicts moderate illness.

III) House Tree Person

HTP designed by John Buck in 1969 is used to measure one’s personality throw

drawings. As the client drew house at left side of paper, it shows that she is self-centered and

self-conscious. The size of house i.e., small shows her unhappiness and insecurity. There is no
 29

detail in house that shows her extreme depression. There is no chimney which indicates lack of

any psychological warmth. The house is without shutter or shades show client’s openness to

contact to environment. Closed door and window show social reluctance. Client drew a tree with

small trunk showing low ego. Split trunk shows split and disorganized personality. Small

branches show difficulty in communicating. There are no leave which indicates depression and

lack of nurturance. Drawing roots at edge shows depressive tendencies. Drawing the person

client draw closed mouth which means rejection of needs. She didn’t draw much detail of face

meaning that she doesn’t need any acceptance and shows indifference. She unusually treated feet

which show depression while closed arms show hostility.

Case formulation

B. U is was a 29 years old lady who had visited two psychiatrists in last 7 months. She had

complained of hallucination along with depressive mood, fatigue, binge eating, insomnia,

suicidal ideation and negative thoughts persistent from last 7 months. The client reported that the

duration of hallucinatory time period is comparatively lesser than depressive mood that is more

persistent even in absence of hallucinations.

The formal and informal assessment of the client points towards the schizoaffective disorder

with depressive type.

The client fulfilled the criteria of the schizoaffective disorder with depressive type according to

DSM-5. She met the criterion A of schizophrenic disorder that included delusions, hallucinations

and disorganized speech. She also fulfilled the criteria of mood episode that was persistent even

in absence of psychosis and it persisted uninterruptedly. The client, during the course of her

illness also reported consecutive weeks of hallucination but the mood symptom (depressive)
 30

were present for the majority of the time. Also, these symptoms were not caused by any

substance intake. The presenting symptoms cannot be better directed towards schizophrenia that

has no mood episodes, schizoaffective bipolar that has depressive as well as manic type, or any

substance induce psychosis.

Schizoaffective disorder fulfill the first criterion of schizophrenia that is presence of two or more

of the following (Peterson, 2018);

 Hallucination

 Delusions

 Disorganized speech

 Grossly disorganized or catatonic behavior

 Negative symptoms including anhedonia, lack of motivation and avolition

Apart from fulfilling the first criteria of schizophrenia, a schizoaffective person had an

uninterrupted episode of mania, depression or both that were persistent for a time period greater

that the time for which psychotic symptoms were present. Schizoaffective person may also report

rapid speech, racing thoughts, agitation, bizarre behavior and delusions (Peterson, 2018).

Predisposing factors in this case are childhood abuse, conflicted parental relationship and

negative relationship experience. Perpetuating factors were extreme parental control, disturbing

domestic environment and loneliness.

 31

Case Conceptualization

Biopsychosocial & Spiritual Model:

Poor Phsycial Health

Overweight Decreased
Binge eating Religiousity
insomnia

Childhood abuse
Low self efficacy
Discrimination
Negative self image
Trauma
lack of worthiness
Physical Abuse
Trauma experience
295.70 (F25.1) Breakup
Schizoaffective
 32

Diagnosis

295.70 (F25.1) Schizoaffective disorder with depressive type was diagnosed using the criteria of

DSM-5.

Management Plan

Following plan is made for the client to amend treat her present psychological complaints;

 Medication

 Psycho-education

 Therapies

 Life skill training and rehab

 Electroconvulsive therapy

Medication

Schizoaffective clients are recommended hospitalization or proper checkup for medical

regulation and supervision. Although, considering her previous record of managing her

psychological issues, she is recommended regular appointments to a psychiatrist for medication

as schizoaffective is a brain-based disorder and therapy cannot treat it alone. Different kind of

medicines are prescribed in schizoaffective disorder including antidepressants, mood stabilizers

and antipsychotics. According to Peterson (2018), 87% of the people with this disorder are

prescribed psychotropic medicines, 93% are prescribed antipsychotic, 48% are prescribed mood

stabilizers and 42% are prescribed antidepressant.

 33

Once the psychotic symptoms are treated through medication, the client is then better

ready for therapies.

Psycho-education

When one know about their illness, they are better able to deal with it. Psych-education

includes educating the client, their family and social group. It helps in understanding the

importance of treatment and ways to reach a goal to eliminate the disease or a disorder. As the

client has a strained relationship with her father, psycho-education of the client’s family is also

necessary because after all the therapies going back to the precipitating environment can trigger

the illness.

Therapies

There are different kinds of therapies for schizoaffective disorder. One of the most

effective therapy for this disorder is CBT.

a) Cognitive Behavior Therapy: CBT is one of most widely used therapy for changing

negative thoughts’ pattern by using ABC model. In this model affects are modified in

such a way that behavior is molded in positive form to bring positive consequences. As

the client has negative thoughts about herself, it is important to change her thinking

pattern. Increased feeling of self-worth will provide motivation to work better on the

treatment plan. It will also help to seek positive lessons from negative events of the life.

b) Interpersonal Therapy: It is an effective therapy for depressive people because it aims

on helping them to interact better with the people they are facing problems with. As the

client has depressive type of schizoaffective disorder, this therapy will help her with

assertiveness, explicit communication and stating the boundaries to other clearly.

 34

c) Mindfulness-based cognitive therapy (MBCT): It includes deliberatively paying

attention to own thoughts. As knowing own thoughts in crucial for higher EQ that helps

in coping own problems and maintaining positive social relationship, it is recommended

as a treatment to client to reflect own thoughts. Journal writing is one of effective way to

reflect own thoughts, thus it is recommended to the client.

Life skills Training and Rehab

There are many organization and support groups that help people with schizoaffective disorder to

get vocational rehabilitation programs, classes and assistance to live as independently as

possible. They also find such people to manage their routine and lifestyle to work, learn and earn

effectively, organizations like National Alliance on Mental Illness (NAMI) and Depression

Bipolar Support Alliance (BBSA) help such people find resources to live an effective life. As the

client has access to internet and gadgets, she is recommended to join such courses and

rehabilitation programs that will help her boost her mental health while providing with skills as

well. Support groups are also an effective way to get through traumatic life experiences by

communicating to people of the same niche.

Electroconvulsive Therapy

It is only recommended when no other medication and non0medication program worked.

It included stimulation of brain area when the patient is under anesthesia. It is more used in

Europe than USA and it is one of the most effective and sophisticated way to help the patients of

psychosis on which no other plan worked (Johnn Geddes, University of Oxford). It is anticipated

that other plans will work on the client due to her resilience she shown in the past.

Suggestions
 35

 Medication and adherence to prescribed course

 Properly following the treatment plan for a significant period of time

 Avoiding the precipitating factors as much as possible

 Seeking positivity provoking sources e.g. reading

 Joining support groups

 Journal writing

 Reading

 Optimized use of gadgets

 Good nutrition and self-care

Prognosis

Positive Points in Prognosis

 Insight of the issue

 Will to amend

 Educated

 Resilient

 Strong and Persistent

 Understanding

 Peer support

Negative Points in Prognosis

 Suicidal tendencies

 Deep rooted hopelessness

 36

 Domestic issues

 Somatic negative thoughts

 Lack of self-confidence and motivation

 37

Case # 3

(314.01)

Attention deficit hyperactivity disorder (ADHD)

 38

Summary

The client was a 9 year old child with persistent problems pertaining to learning,

concentration and hyperactivity. He was brought to hospital by his mother. He was seeking

treatment from POF hospital, Wah Cantt from last few months. Behavioral observation was

done. Connor’s parent rating scale was applied.

Cognitive Behavior Therapy, behavior therapy, Good Nutrition and proper care was

recommended as management plan. The client scored 94 in Connor’s parents rating scale that

indicates severe symptoms of ADHD.

 39

Identifying Data:

Age 12

Gender Male

Father’s Occupation Businessman

Mother’s occupation Banker

No. of Siblings 3

Birth order 2

Number of Sessions 3

Family System Nuclear

Referral Source Mother

Institute POF Wah Cantt.

Reason and Source of Referral

Client’s mother brought him for session as he was not performing well at school. He was

attending more than one tuitions but he hardly passed the exam. He did not respond to instruction

and sometimes he got so angry that he broke things and involved in vandalism. He was only

attached to his mother and listened only to her. It took him a lot of time to complete a simple

homework and did not respond to tutor.

 40

Presenting Complaints

Duration Complaints

1 Years Fidgeting hands and legs

3 Year Lack of concentration

1 Years Vendalism

1 Years Mutism

4 Years Study issues

Behavioral Observation

Client was 9 year old child with a neat and clean appearance. He appeared serious angry

face. He kept moving his leg hitting the table again and again. He looked so indifferent to any

command or instruction. He was not answering anything and seemed so angry for the session. It

took some time to even ask his name but he was reinforced for rewards by his mother to answer.

He then seemed being a little cooperative.

History of Present Illness

Client’s mother told that he was a premature baby and his maternal uncle also had

learning problems. His younger brother was also a premature baby but he is too young for saying

that if he has similar issues too. His older sister is 15 and she was quite good in studies. He was

not much social. When he was admitted to school, he did not make any friends. He paid no

attention to studies nor played any game, instead he manipulated any toy he was given. He
 41

continuously kept fidgeting. He kept hitting things with leg or keeps moving them. Due to

extreme disturbance in studies and paying attention to anything, he was seeking treatment in

POF hospital, Wah cant.

Background Information

Personal History

Birth and Early History

Clients mother reported that he was a premature baby and born through C-section. He

was underweight and was kept in nursery for 48 hours. His bowel movements were delayed and

he still bed wets. His developmental milestones were delayed as well. He started walking at age

of 4 and speaking at age of 6. His sentence was although not yet cleared.

His developmental milestones chart is as follow;

Milestones Normal Range Achieved Age

Cry after birth Immediately after birth Delayed

Neck holding 2-4 Months 6 Months

Sitting 6-7 Months 9 Months

Standing 9-10 Months 14 Months

Walking 12-18 Months 18 months

First word 1-2 years 1.5 year

Sentence 1-2/2-3 years Delayed

 42

Toilet training 2-3 Years 4 Years

Education History

Client was in a private school of quite good reputation. He was student of class 1 and had

failed this year. His problem of learning was less salient back then but now he is presenting more

difficulties regarding concentration. He although liked singing and kept watching TV playing

some music. Other than this, he did not play or watched cartoons.

Psychological Assessment

Psychological assessment was done both at formal and informal level.

Informal Assessment

 Clinical interview

 Behavioral Observation

 Subjective ratings of presenting complaints by mother

Formal Assessment

 Connor’s parent rating scale for ADHD

I) Clinical Interview

Client was interviewed to know about predisposing factors but he did not cooperate

much. He just reported lack of interest in studies and inability to focus, the interview did not last

for more than half an hour.

II) Behavioral observations

 43

The client apparently seemed to be 7 years old. His weight and height was not age

appropriate, his hygiene was maintained. His speech and comprehension was not age

appropriate. he lacked concentration and fidget continuously.

III) Subjective Ratings Of Presenting Complaints

Problems Ratings by mother Ratings by therapist

Pre-requisite skills
eye contact 7 6
Inattention 10 10
Poor imitation 9 9
Developmental skills
Poor self-help skills 7 6
Poor motor skills 5 6
Poor cognitive skills 9 9
Poor socialization 7 8
Behavioral problems
Irritability 8 9

I) Connor’s Parent Rating Scale

The client scored 68 in Connor’s parents rating scale that indicates symptoms getting

more serious.

Case Formulation

Based on administered tests and the information gained through family, client has

problems in learning, sticking to one task, concentration and he also have anti-social behavior
 44

tendency showing from past 1 year. He has all the required symptoms for ADHD. These

impairments have been shown in school, family and society.

According to research, symptoms of ADHD includes inattention, difficulty in sustain

attention, hyperactivity, fidgeting and impulsivity (Timothy et al, 2010). An impaired

functioning in at least two areas (home, study, work, job) is also necessary to be diagnosed with

ADHD (APA,1994). Research also suggests the duration of persistence of symptoms to be

longer than 6 month (APA, 1994).

As the client had persistent symptoms from two years and he had impaired functioning in

home, school and society, with difficulty in attention and hyperactivity including fidgeting, the

client is diagnosed with ADHD. Results of assessment applied on the client were also indicative

of ADHD.

Predisposing factors included premature birth. While there were no apparent perpetuating
factors. Prognostic factor included sex of the child i.e. male, ADHD is more prevalent in males
(Julia et al, 2010). Chances of recovery are also there due to cooperative and financially stable
family as they can afford expenditures of treatment and are well educated.
 45

Case Conceptualization

The following figure shows a summary of child’s problem, various modes of assessment
were applied, different factors contributing to the problems and proposed management strategies.

Presenting complaints Assessment

 Concentration issues  Behavioral observation.

 Hyperactivity  Clinical interview.
 vendalism  Montreal Cognitive
 Academic problems. Assessment
 Not like his age fellows.  Connor’s scale for parental
 Irritable. rating
 Do not understand
Child
commands

Maintaining
Predisposing Precipitating Factors Protective
Factors
factors Factors
 Delayed
developmental  Poor
 premature milestones. Compliance
cognitive
birth.
skills. Supportive
 Birth
 Poor mother.
complications
adaptive
.
skills.

ADHD

Management Plan

 Rapport Building.
 Positive Reinforcement
 Behavior skill training.
 Psycho-education
 46

Table: DSM Criteria for ADHD

DSM 5 Criteria Yes/No
Hyperactivity Yes
Inattention Yes
Developmental level inconsistency Yes
Negative impacts on academic and social activities Yes

Management Plan
The management plan was made according to unique characteristics of the client. It was
directed to manage child’s problematic behavior. Management plan would be implemented on
the basis of behavior therapy.

Short term goals

 Psych education- it was carried out to give idea to mother regarding problem of

child, to discuss management plan with mother and to guide her ways to manage

child’s problem at home.

 Reinforcement- to reduce vandalism and risk taking behavior in the client \

 Making an environment suitable to change client’ behavior

 Concrete and clear verbal instructions to help him better understand and implement

 Praising and reinforcing for positive behavior

 Social skills to help him get along with others

 Support group to make him recover soon and to make friends

 A précised routine easy to be followed by him

 Use short prompt and make him regulate behavior accordingly e.g. ‘stop, do, eat’
 47

 Healthy food

 Good sleeping habit

 Balancing screen time

Behavioral Therapy for Children

It aims at teaching children ways to adjust well by strengthening required behavior. It

eliminates unwanted behavior. It also includes training the parents to help children adjust and

prosper.

Medication

Pharmacotherapy is recommended for immediate recovery. Therapies will help gradually

but in long run.

 48

Case # 4

Drug Addiction Case 3

303.90 (F10.20)

Alcohol Use Disorder

 49

Summary

Client was 25 years old man with persistent problem of substance intake. He had been

brought to hospital by his brother due to client’s behavior getting adverse every day. He

demanded his family for money for drugs and if family refused he threw things at them, used

abusive language and hit himself and others.

Formal and informal assessment was carried out. An interview of the client was taken to

get an insight into the history of his personal life, family and the problems he faced or was

facing. General observation was done. In formal assessment House Tree Person and Drug abuse

screening test were applied on the client.

Drug abuse screening test was administered in which he scored 8 that is evident of

substantial level of degree related to drug abuse.

In the light of presenting issues and assessment the client was recommended immediate

drug detoxification, medication followed by therapies including cognitive behavior therapy and

relaxation therapy.
 50

Identifying Data:

Name ZA

Age 25

Gender Male

Father’s Occupation Labour (Deceased)

Mother’s occupation House Wife

No. of Siblings 5

Birth order 2

Number of Sessions 3

Family System Nuclear

Referral Source Family

Institute POF Wah Cantt.

Source and Reason of Referral

Client’s older brother referred him to hospital due to client demand of money for drug,

bleeding from nose and throwing things for not getting money.
 51

Presenting Complaints

Complaints Frequency Intensity Duration

Alcohol intake 5-10 times a day Moderate-Severe 5 Years

Abusive language Many times a day Severe 4 Years

Anger issues Many times a day Severe 5 Years

Suicidal ideation Once in a day Moderate 2 Years

Worthlessness Twice a day Moderate 3 years

Hopelessness Many times a day Severe 3 years

Fatigue 15 hours a day Moderate 4 Years

Behavioral Observation

The client was 25 years old male with an untidy appearance and entangled hair. He was

not willing to communicate initially. He was continuously itching his arms. He was an introvert

and his speech was unintelligible. It was difficult to make him speak. After asking his name and

few general things about weather, his school memories and favorite food, he felt little

comfortable. He didn’t socialize much and was not maintaining an eye contact. He was so slow

in his movements and his hands were shivering. He was gripping the glass with a firm grasp.
 52

History of Present Illness

His brother referred him to hospital because he was consuming a lot of alcohol and when

he did not find money to buy alcohol, he would beat himself and throw things away. He abuses

others and throw thing at everyone. He was showing aggression and blamed his family to be his

enemy. When he tried to quit drug abuse, he became even more aggressive. He often stayed

outside the house with his friends for many days. The client was losing weight and was

becoming thinner.

The client visited many hospitals and he stayed in one of rehabilitation center for some

time but had to quit due to financial issues. The client first indulged in drug intake 5 years back

after his father’s death. After his father death, he quitted studies and started working in a nearby

shop. There he started alcohol intake due to peer pressure. He was a gentleman and respected his

mother so in start of drug intake, on her request he wanted to quit alcohol intake but his

condition got worse. Now to get alcohol, he threw things and makes fuss in the home. There was

no psychological illness reported in any other member of family.

According to the client, alcohol was his way to escape from painful life. He told that he

wanted to quit but he would end up worrying about life and its adversities. He loved his brother

and upon his requests he agreed to visit the hospital again.

Background Information

Personal History

Birth and Early History: The client was 2nd among siblings in birth order. He was born

through normal delivery and weighed appropriate at time of his birth. First cry after birth was
 53

time appropriate. The client had asthma since childhood He covered her development milestones

age appropriately.

Education History

The client was good in studies. He passed his metric exams with 2 nd division from a government

school but due to father’s death he stopped studying and worked in nearby shop. He was an

average student and he was particularly interested in arts. He used to make painting and he liked

singing.

Sexual History

No sexual disorientation or abused was reported.

Family History

The client belonged to a lower class family. He had 5 siblings. He was 2 nd one. His father

died when he was 18. He quitted studies after that. His mother was house wife and she was

uneducated. He late father worked as a labor. He had good relationship with his family. The

environment of the house before his father’s death was good despite poverty.

His was unmarried. His relationship with mother was complicated after drug absue due to

continuous fighter in the house. He regretted disrespecting his mother and reported that he was

not in his own control. His relationship with brother was although better because e treated him

with love and care.

The authoritative family of the house was his father and after his death his mother and

elder brother took charge of the house. There was no psychological illness reported in any

member of the family.

 54

Drug Abuse

The patient reported intake of alcohol. He reported that he liked weed but it worsen his

symptoms of asthma that he had from childhood.

Forensic History

The patient reported no forensic history.

Past Medical & Psychiatric Illness

The client had asthma.

Pre-morbid Personality

The client was an obedient child and an average student. He was laways an introvert so had only

few friends. After quitting studies, he lost his friends due to no connection with them anymore.

The change in company affected him in many ways including making him learn foul language

and drug intake as well. He was so good in arts, painting and music.

Psychological Assessment

Psychological assessment was done at both formal and informal levels.

Informal Assessment:

 Clinical Interview

 Behavioral Observations

 Subjective Ratings of Presenting Complains

I) Clinical Interview:
 55

Interview of the client was taken to get insight into the persitenting issues of the client.

The interview was conducted for 1 hour and reveal many of the personality aspects, triggering

events and perpetuating factors in client’s life.

The client felt worthless, after his father’s death he quitted studies but he wanted to

become an officer in some prestigious department. He reported that it is money to be blamed that

made him ruin his life. He also reported that he wanted to end his life and he felt like a burden on

his family and a source of sorrow for his mother. The client showed a will to quit drugs.

II) Behavioral Observation

Behavioral observation is a primary technique to decipher non-verbal cues through body

language and expressions of the client during the interview. His vocalization, verbalization,

facial expressions, temperament and general appearance were observed.

The client was 25 years old man with 60 KG weight and 5.9 height. The client hands

were shivering and his movements were slow. His comprehension of the speech was intact but he

had slow speech. His orientation of time, place and date was also normal. He had an insight of

the issue and his will to amend the issue was high.

III) Subjective Ratings of Presenting Complains

Intensity of the presenting problems was assessed on 0-10 point scale that targeted the

severity of the problem. Subjective rating of the scale was done by the client himself to present

the intensity of the problems.

Table 1.1 Patient’s subjective ratings of presenting complaints as reported by the patient

Problematic Area Subjective Rating by the Patient

 56

Low mood 09

Anhedonia 10

Suicidal Ideation 08

Isolation 09

Irritability 10

Fatigue 10

Fear 02

Negative thoughts 08

Aggressiveness 10

Formal Assessment

For the formal assessment of the client following test were used;

I) Drug Abuse Screening Test

II) House Tree Person

I) Drug Abuse Screening Test

DAST-10 was designed to screen drug abuse. It takes 5 minutes to be administered. It is used in

variety of the settings to get a quick index of drug abuse. It is a 10 items scale. It was

copyrighted in 1982 by Harvey Skinner, center of addiction, Toronto, Canada.

Table 1.3: Drug Abuse Screening Test

Raw Scores Category of Depression

 57

8 Substantial level of degree related to drug abuse.

Qualitative Analysis

Drug abuse screening test was administered in which he scored 8 that is evident of

substantial level of degree related to drug abuse.

II) House Tree Person

The client drew a comparatively bigger house than rest of the pictorial contents that

represents overly restrictive and controlling environment of the house. A lack of chimney on the

house represents lack of psychological warmth in client's life. A large roof with terrace

represents his withdrawal from world and involvement with inner life's fantasy. Closed door,

windows and absence of path indicate inaccessibility to the client as he is an extreme introvert.

The client drew an average trunk that represents his inner strength. Branches were empty that

shows his extremely less connection with others. The client drew a figure of human with a bigger

head indicating high imagination and bigger eyes that indicated perception about details of the

world. He drew unusual body with no dress, limbs and hands that indicated his cutoff from

reality.

Case Formulation

The client was 25 years old male with presenting complaints of alcohol intake. The

formal and informal assessments pointed towards Alcohol Use Disorder 303.90(F10.20)

According to general observation, assessment and reported issues by client and his family

it was concluded that client has alcohol use disorder with severity because he was meeting 6
 58

criteria of AUD including increased alcohol intake then intended, strong craving, will to quit but

being failed, gradual increase in intake to get results, problems related to wearing out e.g.,

stomach issues and bleeding and having no interest in things that were once enjoyable e.g., art in

the case of client. Predisposing factors included death of father, quitting studies and bad

company. Perpetuating factors included going back to bad company and consuming alcohol

whenever the client was tensed.

 59

Biopsychosocial & Spiritual Model:

Spirtual Social
Weak connection Peers
with religio or a
higher power Family issues

Biology Psychological
Age Coping skills
Gender Personality type
Disturbed Hormones Alcohol Use Bereavement
Disorder
303.90 (F10.20)
 60

Diagnosis

303.90 (F10.20) Alcohol use disorder

Management Plan

Considering the condition of client, following plan was introduced;

 Attending the support group regularly

 Taking the medicines prescribed by psychiatrist

 Learning management skills

 Developing healthy diet

 Use of reinforcement to reinforce required behavior

Recommendation

Alcohol Detoxification

To bring him back from mass consumption of alcohol to normal level and then gradually

moving towards quitting drug intake.

Cognitive Behavior Therapy

It is important to change negative emotions of client towards himself and others. To

dislike alcohol it is also important to change his cognitions about it.

 61

Relaxation Therapy

To attain a level of calmness and decrease his negativity, stress and anger so that he can

stay calm and assertive in stressing condition and he may not start drug abuse again due to lack

of ability to adjust in adversities of life.

Protocols of All 4 Cases

 62

Case I: Depression with Recurrent Episodes

I) Beck Depression Inventory

63
64
65
 66

II) House Tree Person

 67

Case II: Schizoaffective Depressive Type

I) Beck Depression Inventory

68
69
 70

II) House Tree Person

 71

III) PANSS
 72

Case III: ADHD

I) Connor’s Parent Questionnaire

73
 74

Case IV: Alcohol Abuse Disorder

I) Drug Abuse Screening Test

 75

II) House Tree Person