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PSYCHOLOGICAL EVALUATION REPORT
Socio- Demographic Data
Name: MT SES: Middle class Age: 40 years Gender: Male Qualification: Mechanical B Ed
C.P.NO: 0021752274
Marital Status: Married Informant: Wife Department posting: Psychiatry Referred for: Alcohol Dependence Syndrome
Present Complaints
H/O jaundice which might be due to intake of alcohol No H/O panic attacks Sleep disturbances due to delusional thinking Giddiness, low appetite Alcohol dependence Tobacco intake present Client is a hard drinker Sleep disturbances H/O Hans use in dependence pattern
History of Hospitalization
Onset of Illness Course of Illness(acute/chronic/episodic) Precipitating factors 15 years ago Chronic Peer pressure
Family history:
Client’s elder brother had ADS and died by suicide due to family crisis/stressors 8 years ago
Family tree & details:
Joint/nuclear/extended: Nuclear
Consanguinity: present/absent - Absent
Family history of mental illness/suicide/alcohol or drug use/personality problems/missing
persons, epilepsy (give details): Suicide
Other medical history/condition:
H/O jaundice which might be due to alcohol
H/O habit of hitting himself on the wall after alcohol consumption
Personal Psychological History (one page)
Birth & Early Development Behavior at Childhood Extroverted Sociable School/ Occupation History Had a good relationship with his friends, classmates and teachers. Menstrual History Not applicable Education & occupation History(grade reached, relationship to teachers &peers, other achievement, games, hobbies, abilities) Relationship with friends and teachers was normal during school days. Habit of drinking was developed due to peer pressure
Case history/ Counselling/ Psychometry/ Therapy Observed: (two page)
M is a 40 years old male who is diagnosed with alcohol dependence syndrome came from
a middle class family who was brought along with his wife.
The subject has completed his education in mechanical field and working as a supervisor in
a company.
Reported no history of suspiciousness, talking to self, hallucination, no any other
substance use, panic attack, seizures and asthma.
He has a history of de-addiction in SRMC for the past 15 years.
The client has two elder brothers and he is the third son of the family.
He has 2 children (17 years old son and 15 years old daughter). He doesn’t get along with
his children often, spending time with family is rare. The subject has a history of Hans use
in dependence pattern. He reported past complaints of having jaundice which he suspects
to be because of alcohol use.
The subject consumed Hans (substance) even before the admission in the hospital. He has
sleep disturbances which may be due delusional thinking. The subject seems to be dull and
he has no rapport with the spouse.
The subject seems to be conscious oriented, reactive, denies alcohol craving, speech is
spluttered, attention is normal. The subject has no history of stress, tension, hallucinations
or depressive thoughts. He had normal sexual life and no history of sexual dysfunction.
The subject had an active past life with good friends in childhood. He had a very healthy
lifestyle during the adolescence but started to consume beer at the age of 20 with his
friends. Initially he started drinking once a week but later it turned out to be a hard drinker
after years. He also skipped working for many days. The subject would borrow money
from his friends and spend it on alcohol. He has a habit of hitting himself on wall when
drunk.
There is no sign of anxiety and depressive symptoms, he looks be normal in person.
Summary & Final Formulation (one page)
The subject MT is a 40 years old male who was diagnosed with alcohol dependence
syndrome who comes from a semi-urban family who was brought by his wife.
The subject has a past medical history of de-addiction in SRMC for the past 15 years.
He has completed his education in mechanical field and has been working as a supervisor
in a company.
It is been reported that the subject has a history of consuming alcohol for many years
since he was in his teenage due to the cause of peer pressure.
There is no sign of anxiety and depressive symptoms, he looks be normal in person.
The subject consumed Hans (substance) even before the admission in the hospital. He has
sleep disturbances which may be due delusional thinking. The subject seems to be dull
and he has no rapport with the spouse.
The subject seems to be conscious oriented, reactive, denies alcohol craving, speech is
spluttered, attention is normal.
He is undergoing de-addiction.
Management (one page)
BIOLOGICAL MANAGEMENT:
PHARMACOTHERAPY
Nicotine gum Thiamine Naltrexone – can help reduce heavy drinking Acamprosate – may help the subject to combat alcohol cravings once the subject stops drinking Disulfiram – blocks the metabolism of alcohol by the body causing unpleasant symptoms such as nausea and flushing of the skin. Those unpleasant effects can help some people avoid drinking while taking disulfiram. PSYCHOLOGICAL MANAGEMENT: Behavioural therapy
