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MOJ
eISSN: 2379-6383

Public Health

Case Report Volume 7 Issue 6

Substance induced mood disorder with mixed features

Ammara Asif

Department of Psychology, My Psychologist Community, United Arab Emirates

Correspondence: Ammara Asif, Department of Psychology, My Psychologist Community, United Arab Emirates, Tel 009710504716690

Received: January 01, 1970 | Published: December 18, 2018

Citation: Asif A. Substance induced mood disorder with mixed features. MOJ Public Health. 2018;7(6):37010.15406/mojph.2018.07.00270

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Introduction

Psychological assessment reports

Name:                                 ABC

Father name:                       DEF

Date of birth:                       1989

Date of assessment:            2017

Examiner:                            Dr. Sohail Taj

Identifying information

Name                                  abc

Age                                      26 years

Gender                                Male

No of siblings                       2 (2 brothers

Birth order                            2nd

Family System                    Nuclear family system

Client’s education               Software Engineering (In progress)

Father’s education              Diploma in technical education

Father’s occupation            Retired army Officer

Mother’s education             F.A

Mother’s occupation          House Wife

Monthly Income               125000 R.s

Socioeconomic status         High Class

Religion                              Islam

No of sessions                     8

Informants                          Client and Mother

Referral source

This is the first inpatient admission of this 26 year old, single, male that has 14 years of formal education. He was admitted due to the intake of drugs. The purpose of the current evaluation was to screen for causal factors that incorporate the usage of drugs.

Presenting complaints

According to Client’s

There is a slight nervousness and it looks like a screw. Hand is a copper, it feels bachelor.

Interview information

Onset Illness

When he was16 year old, he started using cannabis. When he was 18, he started Alcohol and heroin. At first he was provided cannabis by his friends. When he used after some months, he started to perceive his imaginary world as real. During this time, he never showed any sign of taking drugs in front of his mother and remained normal. He used to take drugs on daily basis. He had all the knowledge about from where these drugs could be taken. The client’s day-dreaming tendency was also increased with the drug taking. When he started going to college, he developed physiological dependency for the drugs. He was doing Software Engineering when his family came to know about that he used drugs. He passed every semester exams easily. When his conditioned was worse, his parents give treatment at home through Our Organization. He lived for one month on treatment. After that when he met with those friends who were taking drugs earlier, he relapsed because of no care from parents & family issues.

History of present illness

The client was brought to the center by his mother. He was taking heroine in excessive quantity from many years. His company was addict friends. He started smoking cigarette and drugs at the age of 16 years. The client belonged to middle socioeconomic class. He had no good relationship with his father. He most of the times runaway from school and college for enjoy bunk trips with friends and for dates with girl friends. According to him he was punished at school many times but when he entered college he never get punished by teachers. He changed many schools just because of his disobedient and obnoxious behavior. He had many conflicts with his father. According to the client he observed many time silent fights between his mother and step father. He stayed outside with his friends till late night and took drugs. According to him, he suffered low self esteem while having no girlfriend. He spends many nights with girls and involved in physical relationships with them without precaution .He watched blue movies with girls. He starts Marijuana in the age of 16 and takes alcohol occasionally. According to him when he start heroin he stopped Marijuana because he did not satisfy with Marijuana while he start heroin. He used 1gram in starting then he increased quantity with the passage of time. Before the admission in rehabilitation center he took 3gram of heroine on daily basis. He became weak and underweight due to the excessive use of drugs. His mother brought him to the rehabilitation where he was being given both medical and psychological treatment. Before admitting in rehabilitation, he relapsed two times. After completion his treatment he was serious about his life to live better. 

Personal history: The client was born in 1987. He has one brothers and his birth order is Second.

Prenatal and postnatal history: According to his mother, the client was a healthy born child having no problems in achieving the developmental milestones and she didn’t memorize the exact time of achieving of developmental milestone.

School history: The client is doing software engineering. According to him, he can easily pass every exam, but mostly he like school and enjoy college bunks with friends. He ran away from school and smoke cigarette and enjoyed drugs with friends. He always avoids facing his father because he doesn’t like him. His father is step father and there are many conflicts them. That’s why he mostly lives outside with friends and spends time in hanging up. He was aggressive and strait forward.

Work History: He is a student and has no work experience.

Relationship with peers: The client had friends at neighborhood in college and university. Firstly his friends were non smokers and drug users but when he started using drugs his friend’s circle got changed into smokers and addict at the age of 17. He has also relation with girls and has involved in physical relations with them many times .He watched blue movies with many girls. He has emotional attachment and physical relation with one girl -but when parents of the girls came to know about the addiction problem they left the client. According to client, his friends always used him, although they have money but they never used their own.

Premorbid personality

The client was a healthy child, but tensed because of his parents conflict .He enjoy his life openly with friends and show dominating personality to avoid the sadness. He used to play games like cricket and hanging out with friends. His home environment was not restrictive. He was naughty and pampered by his mother. He had a healthy relationship with his family and relatives except father.

Researchers

Two epidemiological researches have examined the prevalence of psychiatric and substance use disorders by conducting diagnostic interview surveys in representative group of people adults sample: the National Institute of Mental Health Epidemiologic Catchment Area (ECA) study1 conducted in the early 1980s and the National Comorbidity Survey (NCS) conducted in 1991.2 Both provided striking documentation that mood disorders increase the risk of SUD. Studies of individuals in search of treatment have resulted in variable estimates of the co morbidity of mood disorders and SUDs. Among those seeking treatment for alcohol dependence, an estimated 20 to 67 percent had experienced depression and 6 to 8 percent had experienced a bipolar disorder at some time in their lives.3 Before attempting a definitive diagnostic assessment, it is best to wait until the patient has had a reasonable period of abstinence. Doing so gives symptoms of acute intoxication and withdrawal time to subside. For example, a number of studies have found a 30 to 50 percent decrease in depression rating scores from the first day of abstinence to the end of the second week.4 In inpatients with alcohol, cocaine, or opioid dependence followed for 1 year after discharge, Nunes and colleagues reported that 57% met DSM-IV criteria for a major depressive episode. Whereas 51% of the sample had initially been classified as having SIMD at admission, only 14% of depressed patients were classified as having SIMD at follow-up. Patients initially classified as having substance-induced depression at baseline were equally likely to have a major depressive episode during follow-up compared with those initially classified as having MDD; in the group of depressed patients as a whole, the mean number of weeks spent depressed over 12 months was 25.6 (SD 15.3).5

Medical history

The client suffered from many medical ailments like Ulcer, appendix operation, migraine, jaundice disease. He was underweight according to the age. He faced an accident when he was in university by his friend rush driving after taking drugs on that time he suffered from minor injury. According to the client, he has not been tested for HIV, Hepatitis B/C, Tuber sclerosis and sexually transmitted diseases, but client mother and aunty is suffering from obsessive compulsive trends.

Family history

The client belonged to high socioeconomic class. His father was army retired person .He is client’s step father. They have good relationships with their other relatives.

Relationship with mother

He has a very good and loving relationship with his mother. He is very attached to her. When his mother came to know about smoking cigarette, she got worried and asked for leave that habit. The client was reported that at many times he promised to stop smoking cigarette and taking drugs but he couldn’t control so every time he lies to his mother just for her satisfaction.

Relationship with father

He has lot of conflicts with his father. Client has reported that his father is step father. His step father is aggressive, argumentative in nature. He lived one week with client’s family and one week with other family where he has second wife and children. Client has good relation with step siblings. When his father came to know about his drugs problem, he became much aggressive and try to resolve conflicts between himself and the client but was not resolved because client doesn’t want to communicate even.

Relationship with siblings

He has good relationship with his brother who live abroad and with six step siblings-and he communicates with them in a friendly way. Client used to spend most of his time with friends, just for using drugs.

Test administration

Psychological Assessment: Assessment has been at two levels:

  1. Informal assessment
  2. Formal assessment

Informal assessment

In the case of informal assessment behavioral observation and mental state examination has been done.

Behavioral observation

The client was sitting in a straight posture and was showing a good behavior. When the interview started, the interviewer introduced herself to the client. He was asked to tell his name, age and other identifying information. Many times it was noticed by the interviewer that he was giving only short information at some points during the conversation. He was probed many times to answer honestly and also encouraged to inform in detailed. He was wearing a clean dress. He was not looking happy. He was not confused at any point and was answering the questions properly. He was quite submissive during the first session and was listening to all the questions. His behavior was also good with the psychologist.

Behavioral observation during testing session

Rapport developed easily. Client maintained good eye contact and was attentive, motivated and willing to provide information. He was preoccupied with conflictive attitude of his father and caring nature of his mother. During HFD he was looking normal and easily draws the figures. During TAT Administration he told stories with excitement. During BGT, and SPM he showed curiosity about tests. In the entire sessions he cooperated well with the examiner.

Mental state examination

  1. Appearance: Client was observed during all the sessions. He was looking underweight. His dress was clean and was sitting in a straight posture.
  2. Behavior: In first session, he was sitting in straight posture but feeling body cramps in (joints, elbow, legs). He was quite cooperative but in first 2 sessions he could not perform the test because of body cramps .He had proper gestures and expressions according to his conversation when he was telling something. He had adequate facial responses and was proper maintaining eye contact.
  3. Attitude: The client had a very cooperative attitude and listened to the questions asked. He never distracted by outside activities going on.
  4. Level of consciousness: The client was consciously aware of his session he was normal neither elevated nor depressed in the first session. But he was looking dull during the first sessions because of body cramps.
  5. Orientation: He had proper orientation of person, place and time. He was able to tell the name of the place, date and time and also the name of the center.
  6. Speech and Language: His language and speech was adequate according to his age. He had normal rate of speech and volume was soft. He had clear speech . He was talkative in all sessions.
  7. Mood: In all session his mood was neither elevated nor depressed. He was sad and had a guilt feeling about his drug life. According to the client, he wanted to back his home.
  8. Affect: He was expressing his feelings properly. His mood was consistent with the feelings. He was sad and had a guilt feeling about his drug life and the goal which he cannot achieved. His mood was not intense and remained consistent with his thought content.
  9. Thought Content and Process: He was not having any problem with the thought content. He was angry because he was missing his home and mother.
  10. Insight: The client was able to understand his problem of drug use. He knew that drugs spoil his life and that’s why he was brought to the center. He also knew that it was just because of the company of the drug addicted peers.
  11. Perception: The client faced tactile hallucination like someone moving fingers in his hair when he was in matriculation but after 2 to 3 months again he doesn’t feel hallucinations or delusions neither he detached from the environment.
  12. Attention: He was able to do simple calculations and able to spell his name and simple words. He was attentive to the psychological tests.
  13. Memory: He was open and good in memory because he was describing his past memories and activities very clearly. He was able to memorize the instructions. He also had good short term memory as he told about his routine at the center.
  14. Suicidality and Homicidality: The client was quite unhappy with his life, according to him, he sometimes thinks that his life is boring but he was quite hopeful to live a better life and achieve his goal after going back home. He had no desires of hurting others or himself. He was quite aggressive in nature.

Formal Assessment

Keeping in view the symptoms and problems reflected in the behavior of client, as well as reported by others, following tests and scales were used for the formal assessment to have clear idea of the problem:

  1. Mental status Exam (MMSE)
  2. Human Figure Draw (HFD)
  3. Standard Progressive Matrics (SPM)
  4. Bender Gestalt Test (BGT)
  5. Thematic Appreciation Test (TAT)
  6. Rotter Inkblot Sentence Blank (RISB)
  7. Aggression Questionnaire (A.Q)
  8. The Manifest Anxiety Scale ( MAS)
  9. Psychological Interpretation
  10. Human Figure Draw (HFD):
  11. Emotional Indicators:
  12. Sensitive to criticism
  13. Anxiety
  14. Psychosomatic Complaints
  15. Manic tendencies
  16. Helplessness
  17. Aggression
  18. Need for affection(Nurturance)
  19. Poor Self Control
  20. Maternal Dependency
  21. Standard Progressive Matrices (SPM)

Quantitatively

The total score obtained the consistency of estimated and the grade reached is conveniently summarized as:

Total score……………..... 25

Discrepancies…………..... +2, 0, -1, -2, +1

Grade……………………… V

Percentile…………………at the 5th percentile

IQ………………………... 75

Qualitatively

The total score of client is 25. Discrepancies +2, 0,-1,-2, +1are involved. Client has lie on 5th percentile that is V grade. The level of client I.Q. is 75. This I.Q. level shows intellectually deficit. In intellectually deficit, two major areas are impaired i.e., the most obvious characteristic of the intellectually deficit is their reduced ability to learn, compared to their normal peers of the same chronological age. The ID individuals have difficulty in a tending to a variety of stimuli, they are characterized as being easily distracted and possessing very short attention spans.

Thematic appreciation test (TAT)

The client tells different stories on different cards, which show his conflict, drives and presses. Most of the client’s stories on different cards show the need for achievement, need for acquisition, self image and high affectional needs. These stories also show parent conflict, Verbal aggression, guilt, sexual conflicts, anxiety, avoidance and dominance and press the theme of infidelity. The client also used different defense mechanisms in different stories such as, projection rejection, repression and rationalization.

Rotter’s incomplete sentence blank (RISB)

Quantitative Scoring of client: (Table 1).

Domains

 

Scores

Conflict Response

C1

28

C2

35

C3

36

Positive Response

P1

12

P2

8

P3

0

Neutral Response

N

3

Total

 

122

Table 1 Quantitative scoring of client

Qualitative Interpretation: The total score of the client on RISB was 122 which are below the cut off score i.e. 135. These scores indicate that the client was adjusted in the environment. The client gave one response on neutral, 15 mild and moderate conflict response as compared to19 positive responses. The client was optimistic toward his goal. Many of the responses were related to this drug addiction. He wants to get rid from drug addiction. He had show affection towards his mother. He showed conflicts with his father.

Bender Gestalt Test

Quantitative Scoring: (Table 2).

Designs

Design total

Design 1

20

Design 2

20

Design 3

2

Design 4

0

Design 5

2

Design 6

2

Design 7

0

Design 8

2

Configuration Design

10

Total Raw Score

58

Z score

92

Table 2 Quantitative scoring

Qualitative Interpretation: The Z scores of the client are 92 which is way ahead of the cut off score which is 72. Such high scores are indicative of little ego strength, cognitive deficits and mental deficiencies. Deviation pattern like less number of dots, work over angles show mental deficiency or brain damage. This case is easily spotted as extremely ill individual in poor contact. The client therefore has high perceptual deficiency, low maturation, and severe psychological disturbances according to the BGT scores. Poor contact and psychological disturbance are obvious in drawing of substance users.

Aggression scale

The total questions are 67. It consist of four subscale including Physical aggression (1 to 9 items) he scored 24,on verbal aggression (10-14) and he scored 20, Anger ( 15-21) he scored 15, Hostility (22-29) here he scored 8 which indicate his high level of physical and verbal aggression

The manifest anxiety scale ( MAS)

Qualitative Interpretation: The total score of the client is 22 and cut of scores are 25 which manifest anxiety (Table 3).

Tentative diagnoses

Axis I

-292.84

Substance induced mood disorder with mixed features

Axis II

V71.09

No Diagnosis

Axis III

 

Ulcer, Jaundice, Migraine, Appendix

Axis IV

 

Conflicts with Step father, Aggression, Sexual conflicts

Axis V

 

GAF = (61 to 70)

Table 3 Qualitative interpretation

Prognosis

On the basis of client’s age, family support and psychological evaluation results; prognosis Seems to be favorable.

Recommendations

  1. Cognitive Behavioral Therapy
  2. Moral sexual Therapy
  3. Interpersonal Training Skills
  4. Relapse Intervention Skills Training

Acknowledgments

Primarily I am grateful To ALLAH SUBHANA-O-TALAH. It is Who created us, sanctified us with diverse competencies to overcome impediments of life. We are nothing buy what He has granted us with. All admirations are for Him, for He has assigned me the vigor to complete this work. Writing a clinical research report is a task that involves many people So I owe a special debt for our instructor in this clinical work, Sr. Saim whose support, encouragement and proficiency guided us to successfully complete my report. He endowed with his expertise and thoughtful comments that directed me through the completion of my project of clinical reports. Many thanks to my Husband , always a source of my strength , his honorary presence and voluntary assistance in the duration of taking case histories in My Psychologist. I would like to express my deepest gratitude and love for my parents and my siblings, who were and are constantly an oblige for my vitality to tackle hurdles of life and are central to my every success.

Conflicts of interest

Author declares that there is no conflict of interest.

References

  1. Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. Journal of the American Medical Association. 1990;264(19):2511–2518.
  2. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Archives of General Psychiatry. 1994;51(1):8–19.
  3. Brady KT, Myrick H, Sonne S. Comorbid addiction and affective disorders. In: Graham AW, Schultz TK, editors. Principles of Addiction Medicine. 2nd ed. Arlington; American Society of Addiction Medicine; 1998:983–992.
  4. Goldsmith RJ, Ries RK. Substance-induced mental disorders. In: Graham AW, Schultz TK, editors. Principles of Addiction Medicine. 3rd ed. Chevy Chase; American Society of Addiction Medicine; 2003:1263–1276.
  5. Nunes EV, Liu X, Samet S, et al. Independent versus substance-induced major depressive disorder in substance-dependent patients: Observational study of course during follow-up. J Clin Psychiatry. 2006;67:1561–1567.
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