Clinical Case History: Mr. Ankit

Name: Mr. Ankit

Age: 28

Gender: Male

Setting: Care Foundation

Primary Concerns: Smack (opioid) dependence, psychotic symptoms, impaired self-care

Services Involved: Psychiatry, Clinical Psychology, Counselling, Psychological Assessment

Presenting Complaints

Mr. Ankit was admitted to Care Foundation with a long-standing history of smack dependence, accompanied by significant deterioration in self-care, behavioural instability, and symptoms consistent with a psychotic disorder. Family members reported social withdrawal, suspiciousness, disorganised behaviour, and a marked decline in daily functioning.

History and Course

The client had been using smack for several years, resulting in substantial impairment across personal, social, and occupational areas. Over time, he developed features of substance-induced psychosis, including disorganised thought processes and behavioural abnormalities. By the time of admission, his self-care and daily functioning were severely affected.

Assessment Procedures

A comprehensive evaluation was conducted by the multidisciplinary team, which included:

• Clinical Psychiatric Evaluation
• Mental Status Examination (MSE)
• Psychodiagnostic Tests:
  • Sentence Completion Test (SCT)
  • Draw-A-Person Test (DAP)
• Structured clinical interviews and behavioural observations

These assessments provided detailed insight into his personality dynamics, emotional functioning, cognitive processes, and the psychological impact of long-term substance use.

Treatment Plan

1. Pharmacological Management – Medication was initiated and closely monitored to manage psychotic symptoms, stabilise mood, and reduce cravings.
2. Psychological and Counselling Intervention – Regular counselling sessions focused on motivation enhancement, relapse prevention, coping strategies, psychoeducation, and supportive therapy.
3. Rehabilitation and Self-Care Training – Interventions targeted daily living skills, hygiene, behavioural activation, and developing a structured daily routine.

Outcome and Progress

The client showed steady and consistent improvement. Psychotic symptoms reduced substantially, emotional stability increased, and self-care gradually returned to normal. He demonstrated strong medication adherence and actively engaged in therapeutic activities throughout rehabilitation.

Current Status

Mr. Ankit is now clinically stable, abstinent from substance use, and functioning independently. He is living at home, performing daily tasks effectively, and continues with periodic follow-up sessions to maintain long-term well-being.