Name: PARIDHI CHOUDHARY

College: VIVEKANAND EDUCATION SOCIETY’S COLLEGE OF ARTS,

SCIENCE AND COMMERCE

Programme: MASTER OF ARTS (PSYCHOLOGY)

MAPC IN CLINICAL

No of Days in Internship: 20 DAYS (120 HOURS)

Internship from: 16th DECEMBER 2024 - 22nd JANUARY 2024

 CASE 1

CASE HISTORY

Name: VS

Age: 24

Sex: Male

Education: BCOM

Religion: Hindu

Socio-economic Status: Low

Employment History: Relation Manager/Cashier

Area of Residence: Bhiwandi

Date of Admission: October 16, 2024.

Hospital: Regional Mental Hospital, Thane.

Ward: M2

Diagnosis given (by hospital): Schizophrenia

COMPLAINTS AND DURATION:

V.S. reported having problems with OCD. He reports repeatedly seeing faces of people he

had seen since 9th grade. By seeing these faces repeatedly he reported engaging in reported

behaviour such as constant mumbling and muttering about how he shouldn’t be seeing faces

and it's all ‘mann ka vehem’. He reports reduction of these symptoms since being on

medication in RMH. He stated that these faces were of people he met (on the street or in his

family) and persisted for only 2-3 seconds, and that the face would be replaced with the next
person he would meet. He felt that these thoughts were intrusive and bothered him a lot, and

the only way he could ease his mind about seeing these faces was to mutter to himself.

HISTORY OF PRESENT ILLNESS:

He first sought treatment for his problems in 2018 at JJ Hospital, where he was accompanied

by his parents. He stated not benefiting from the treatment provided, due to which he went on

to seek treatment with a few local clinics, emphasizing that there were no improvement in his

symptoms at this time. He was later admitted to the Regional Mental Hospital, Thane in 202,

for a period of 3 and a half months, during which he reported significant improvement, post

which he was discharged. He had been readmitted to RMH on October 16, 2024 (2 months

before date of evaluation) following a reported breakdown, during which his symptoms

worsened and he experienced increased anger and irritation. He also stated that he allegedly

hit his mother during this outburst, following which he was readmitted. V.S. was diagnosed

with Schizophrenia, and has been receiving treatment and medication for the same. He

reports significant improvement of his condition since receiving treatment.

Onset: V.S. reported that he began seeing faces repeatedly (of people he met) for 2 seconds

and mumbling to himself that this isn’t real and everything will be alright after the death of

his Badi mummy in 2016. He reported not being able to deal with her death and seeing the

dead body disturbed him. He mentioned being confused about death and why it has to

happen. Further he mentioned that he used to stay isolated and would often mutter things to

himself, which was perceived by his family to be odd and peculiar. He reported that it was

around this time that he was highly irritable and used to snap at others.
Predisposing Factors: None Reported

Precipitating Factors: Death of a family member (Badi Mummy). He reported being unable

to cope with it.

Perpetuating Factors: Instances of Social Ostracization and Bullying from peers about his

behaviour.

Protective Factors: V.S. reported having supportive parents and sister. He appeared to be

resilient and social, often interacting with others in the ward, and he also reports having an

optimistic outlook towards his recovery.

Course of the Illness: Gradual (currently in recovery)

Associated Disturbances: V.S. reports outbursts of anger during the course of his illness. He

reports lashing out on his mother and hitting/pushing her in anger. He reports experiencing

anxiety and fear when repeatedly seeing faces which he says leads to him mumbling and

muttering about how he shouldn’t be seeing faces and it's all ‘mann ka vehem’. In the

hospital he reports talking to other patients. He reports no difficulties with sleep, appetite,

bowel movements and ADLs.

Treatment: He receives 1 injection a day (a mixture of Seronac 10mg and Finargan 50mg)

and 3 tablets twice a day (Olanz 10mg, Escazin Plus 101 and Larpoze 2mg).
PAST HISTORY

Other than the presenting complaints, he reported no prior medical or psychiatric illnesses.

FAMILY HISTORY

V.S. reported living with his parents- his mother (46) is a housewife and his father (52) is a

rickshaw driver- and his elder sister (26) is an IT engineer. He mentioned having good

relationships with his family, and them being overall supportive. He also mentioned frequent

visits from his family to the facility. He also stated that his father was a middle child, and had

2 brothers, with his “Bade Papa” (father’s elder brother) also being an auto driver, who was

married but lost his wife to a heart attack in 2016 and had a history of consuming tobacco,

and his “Chachu” (father’s younger brother) being a bus driver. He also mentioned his mother

having a younger brother. He mentioned that all of them live in close vicinity, but gave no

further indication of any other family members. Attached below is the family genogram (as

reported by V.S.)
PERSONAL HISTORY

Birth and early development: Reports normal birth, no complications.

Behaviour during childhood: He reports being generally quiet as a kid and having few

friends. After onset reports being teased from his peers in school for his mumbling and

muttering, and reports having lost a lot of friends.

Physical illnesses during childhood: None reported

School: Reports going to a semi-english school and describes himself as being a quiet child,

but was good at academics, with history and geography being favourite subjects. He liked

taking part in speeches.

Occupation: His first job was post graduation, as a cashier in Dmart. He reports to have liked

working there. Most recently worked in a bank as a relations manager. Reports having a good

relationship with his boss. Experienced difficulty with his job and left, was then admitted to

hospital. He reports that he likes working and mentions wanting to go back to working as a

cashier in a mall after his recovery.

Menstrual history: Not applicable

Sexual history: None reported.

Marital history: Unmarried. No relationships reported. Reports to not engage in marriage or

relationships until he has recovered.

Use and abuse of alcohol, tobacco and drugs: Denies use of substances.

NEGATIVE HISTORY

No substance use history, no sexual history, no marital history.

PREMORBID PERSONALITY

Attitudes to others in social, family and sexual relationships: Normal, with good outlook

towards relationships, however has some reservedness and suspiciousness and worries that

“some people are bad and might teach me bad things.”

Attitudes to self: Optimistic, Resilient and Positive Self-image

Moral and religious attitudes and standards: Reported being religious (Follows Hinduism)

and mentions praying on a daily basis.

Mood: Normal

Leisure activities and interests: Reported enjoying cycling, badminton, watching movies

and comic interactions (comedy club)

Fantasy life: None reported

Reaction pattern to stress: Talking it out with family members, praying.

Habits: None reported.

A DAY IN THEIR LIFE

In the facility, V.S. starts his morning at 5am, after which he takes a bath, and then helps

clean the ward. Post this he has breakfast and his medicines and then indulges in watching

some TV and talking to his cellmates. Post this, he has lunch and another round of medicines,

and takes a nap after cleaning again. In the evening, he enjoys comedy and shayari with his

cell-mates and friends in the facility and then has dinner and final round of medicines for the

day, and goes to bed at around 10pm.

COPING STYLES

V.S. showed signs of being optimistic and resilient. He said that in moments of stress he turns

to his family, friends and God. He enjoys working through problems and tries to look at the

bright side of things.

 MENTAL STATUS EXAMINATION (MSE)

GENERAL BEHAVIOUR

V.S. appeared well-groomed and hygienic for the testing session. He was fully conscious,

relaxed and held his attention. He maintained adequate eye contact and was cooperative.

PSYCHOMOTOR ACTIVITY

He showed normal psychomotor behaviour and activation.

TALK

Amount of speech: Normal

Tone: Normal

Tempo: Normal​

Reaction Time: Normal

Speech coherent, relevant and responds to questions.

THOUGHT

Stream: Normal

Form: Normal, no presence of formal thought disorder detected

Posession: None detected

CONTENT:

Normal thought content, no disturbing ideation.

MOOD:

Euthymic and congruent

PERCEPTION

No presence of any issues with perception

COGNITIVE FUNCTIONS :

●​ Attention and concentration: Distorted, was unable to perform the serial subtraction

task

●​ Orientation: Intact

○​ Name: V.S.

○​ Place: Thane Mental Hospital

○​ Date: 16 December 2024

○​ Time answered: 12:30 Actual time: 12:40

●​ Memory: Intact

○​ Immediate Memory: Intact

Repetition: Accurate

○​ Recent Memory: Intact

Breakfast- Usal Bread; Events of the day- Woke up, Bath

 ○​ Remote Memory: Intact

Personal childhood event: School Speech

○​ Recall: Intact

Presented 3 words (blue, banana, cow) and asked to recall after some time.

●​ General information: Appropriate

○​ Name of the Prime Minister: N. Modi

○​ Major cities in India: Mumbai, Delhi, Kolkata, Chennai

○​ Name of the state and Capital: Maharashtra and Mumbai

○​ Names of a few countries: India, Canada, Japan, USA, France

●​ Intelligence: Appropriate

●​ Judgement: Appropriate

(a) Personal Judgement: Intact

Current proble? Yes it is an illness, mental illness, but I am going to better

What are your future plans? - Make parents proud

(b) Social Judgement:

If 2 people are fighting what should be done? Tell them not to fight

(c) Test Judgement:

What would you do if a stamped, sealed, addressed envelope is found in the street? -

Post it

●​ Insight: Intact
 CLINICAL ASSESSMENT

Tests Conducted

Rorschach Inkblot Test (ROR)

Millon Clinical Multiaxial Inventory-3 (MCMI-3)

Sentence Completion Test (SCT)

RORSCHACH INKBLOT TEST (ROR)

The Rorschach Inkblot Test is a psychological assessment developed by Hermann Rorschach

that uses inkblots to evaluate a person’s personality presentations, emotional functioning and

thought processes and helps detect presence of any pathology. It gives insight into a person’s

thought organization, self-image, interpersonal relationships, traits and underlying thought

disorders. It is a projective test, making it harder for individuals to manipulate responses by

indulging in random responding or faking good (to show a socially appropriate image) or

faking bad (to overreport or over exaggerate their symptoms.)

The test yielded a valid protocol, which indicates that the data derived, is likely to be a valid

representation of V.S.’s personality pattern. Based on analysis of V.S.’s scores, it can be

understood that this person has no obvious problems with issues of control por stress

tolerance. He appears to have as much resource available as most adults. It can be inferred

that he is not currently experiencing any noticeable distress that impacts his control capacities

(which is in line with his case history.) Additionally, the impact of situational stress would

usually be mild to moderate, depending on the nature of the situation, with very little to no

impact on his thoughts and emotions, which is further highlighted by his hopeful and

optimistic outlook towards his treatment and life.

Test findings further indicate that he is not prone to any significant affective problems and

does not face any noticeable or profound difficulty in social adjustment. His coping style is

more avoidant-extratensive in nature, with more emphasis/reliance on intuition. He might be

likely to use his feelings more directly in decision making by merging them with his

thoughts. He is more dependent on external feedback, and is influenced by emotions in

comparison to others, and might prefer to do things through trial and error, and he might be

more tolerant and less concerned when problem-solving errors occur. He might be more

cautious and conservative with processing information, but does so effectively, and is likely

to economize resources and avoid complexity. Additionally, he does not experience difficulty

in shifting attention. His cognitive mediation is appropriate, with his conventional reality

testing being largely intact, with mediational dysfunction being at par with most people.

His self-esteem and self-involvement is at an average level and there is no indication of him

overvaluing his worth, indicating a more realistic sense of self. Moreover, his scores indicate

that he does not spend a lot of time ruminating on himself, and his self-image does not

include negative or blemished features, and is not based on imaginary impressions or

distortions of real experience.

Test findings further indicate that there are no significant interpersonal difficulties, and that

his perception of others is not unrealistic or problematic. He is adequately socially mature

and does not experience any difficulty in interacting with others and the environment, which

is in line with his case history. He is not overly cautious in his interactions with people, and

tends to have an overall positive view of people, with a generally trusting nature. He is open
to forming and maintaining close emotional and physical relations. His interpersonal

activities are likely to be viewed positively by others.

SUMMARY FOR ROR:

The findings on V.S.’s Rorschach protocol suggest that his functioning is adequate,

appropriate and is not marked with any significant interpersonal or intrapersonal difficulties,

as in line with his case history.

 MILLON CLINICAL MULTIAXIAL INVENTORY- III (MCMI-3)

The Millon Clinical Multiaxial Inventory- III is a psychological test used to assess the

presence and severity of personality and symptom disorders in adults. It is usually used with

the clinical population (people who are undergoing psychodiagnostic evaluation or

psychotherapy) to investigate personality traits, disorders, symptoms and their severity. It is

an objective test containing 175 items with a dichotomous responding pattern (true and false),

and takes approximately 30 minutes to administer.

For the purpose of assessment with V.S., the Hindi version of the MCMI 3 was used. He was

able to understand the items with minimum clarification and was cooperative and willing to

participate in the testing process. Upon analysis of his responses, validity of the profile was

established, indicating that he was true in his manner of responding. V.S.’s score suggest that

he requires constant attention, praise and admiration. He might appear conceited or haughty

and at times pretentious. He might have a tendency to be self-centred and might

expect/demand social favours. This was contrary to the observation by the examiners and his

case study, which might indicate that he might have presented a good image at the time of

assessment. Furthermore, he might have a tendency to to be behaviourally rigid, meticulous

and over-conforming at times. He might appear perfectionistic, moralistic, formal,

cooperative, flexible and organized. He might have the tendency to suppress strong

resentment and anger towards others (like authority figures) and appear polite and respectful,

especially towards those whose approval he seeks. He has a strong sense of duty and strives

to avoid criticism, and may present himself with propriety due to fear of said criticism. He

may also exhibit obsessional thinking. Therefore, his MCMI findings indicate that he might

have narcissistic and compulsive personality traits.

 SENTENCE COMPLETION TEST (SCT)

The SCT was administered on V.S. and it was found that he is very family oriented. He

claims to feel proud when he does something for his parents. He views his parents to be

god-like and says that his family is happy and successful. He also said that his mom misses

him a lot, and that he fears that his mom might get distanced from him, further emphasizing

their close relationship. He also desires to get his sister married off in a good manner.

He said that other people usually talk bad about others, and that he hates people who teach

him bad things, but he also said that he hasn’t experienced that much in his life. He claimed

that his friends and neighbours are good to him and are his well-wishers. He himself tries his

best to see the good things in people and does not like talking ill about people behind their

backs. He believes that good relationships must be maintained and quarrels should be

resolved.

He said that he feels good most of the time and he gets angry/worried when he experiences

bad thoughts and that he experiences difficulty in controlling his anger. He hopes and dreams

to be a good and succesful person, and expresses his desire to know about his responsibilities.

He emphasizes progress and requently wonders why people suffer from poverty. He further

says that if he was someone successful (like the Prime Minister) he would do good for the

country and try to help people. He has strong sense of morals/duty and also thinks of suicide

as morally wrong. When asked about his past, he says that his past was very good, and he

enjoyed his childhood (when he was extremely mischievous), liked going to school/doing

homework (esp subjects like history and geography). Presently, he enjoys cycling and likes

listening to music. He is religious and believes that God will do good for him.
 CASE FORMULATION: BIOPSYCHOSOCIAL MODEL

For the purpose of better understanding this case, we can conceptualize it using the

biopsychosocial model, which is a holistic model to understand health and illness, by

examining the interconnected role of biological, social and psychological factors.

1.​ Biological Factors: Not applicable, but hypothesized reason (as this was not

confirmed by him) could include an undiagnosed presentation of OCD in one of his

first degree relatives

2.​ Psychological Factors: Some possible psychological factors include

○​ Personality Dispositions and temperament: He possesses traits of

compulsiveness, which might explain the current presentation of the disorder.

○​ Defence Mechanisms: He might have used defence mechanisms of repression

and suppression, as he evidently tried to engage in self-muttering behaviour to

disengage from the thoughts.

○​ Erikson’s Stage: Ostracization from peers during his school (at the stage of

Industry vs Inferiority) could have contributed to his feelings of inferiority.

○​ Dominant Superego: His mutterings indicated behaviours of “I shouldn’t do

this” or “this is wrong” and his views about the role of his parents indicates a

dominant superego functioning.

○​ Cognitive Distortions: Use of cognitive distortions or fallacious reasoning

(like should statements) could have had a noticeable impact on his thoughts

and perception, further contributing to the manifestation of the disorder.

3.​ Social Factors: A predominant social factor is witnessing the death of a loved one

(his badi mummy) and ostracization from peers for his self-muttering behaviour in his

high school years. Another contributing factor could be his lower socio-economic

status.
 PROVISIONAL DIAGNOSIS

Based on the case history and clinical assessment conducted on V.S., it can be said that he

meets the criteria for Obsessive-Compulsive Disorder (OCD) (image type). As per the

DSM 5 TR criteria:

A. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

1. Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time

during the disturbance, as intrusive and unwanted, and that in most individuals cause

marked anxiety or distress.

2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to

neutralize them with some other thought or action (i.e., by performing a compulsion).

Compulsions are defined by (1) and (2):

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g.,

praying, counting, repeating words silently) that the individual feels driven to perform in

response to an obsession or according to rules that must be applied rigidly.

[Link] behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or

preventing some dreaded event or situation; however, these behaviors or mental acts are

not connected in a realistic way with what they are designed to neutralize or prevent, or are

clearly excessive.

In V.S.’s case, he reports obsessions in the form of images (seeing faces of people he met)-

which is distressing and invasive to him and he wishes that these thoughts would go away. He

reports compulsions of engaging in self-muttering behaviour in response to seeing the faces.

This behaviour, according to his testimony, helps him calm himself and deal with the distress

and panic that is caused due to seeing those faces.

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per

day) or cause clinically significant distress or impairment in social, occupational, or other

important areas of functioning.

The obsession and compulsion were hindering his interactions in school and at home, where

he saw others frequently making fun of him and his family regularly being inconvenienced or

“burdened.” He also reported that when these symptoms were occuring on a daily basis, it

used to consume a lot of his time, and at times he would engage in the self-muttering

behaviour for hours.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a

substance (e.g., a drug of abuse, a medication) or another medical condition.

V.S. denied ever consuming any substances in his life and does not have any medical

conditions, therefore his behaviour cannot be attributed to the effects of any substances.

D. The disturbance is not better explained by the symptoms of another mental disorder

(e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance,

as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in

hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin

picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement

disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances

or gambling, as in substance-related and addictive disorders; preoccupation with having

an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic

disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty

ruminations, as in major depressive disorder; thought insertion or delusional

preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive

patterns of behavior, as in autism spectrum disorder).

Based on the case history, clinical assessments and observation, it can be ascertained that V.S.

is not presenting signs or symptoms of any other disorder.

Differential Diagnoses:

Anxiety Disorders: Since his concerns or distress is not based on real-life situations, we can

rule out Generalized Anxiety Disorder. And since his obsessive thought is followed by a

compulsive behaviour or “ritual”, we can rule out Specific Phobias (as they usually have

specific triggers but are not followed by a ritual.)

Eating Disorders: The nature of obsessive thoughts and compulsive behaviour were not

related to concerns of health or weight. Furthermore, no history of eating disorder was

reported, and his food intake and appetite were reported to be normal.

Tic Disorder: No history of any tics or mannerisms. Furthermore, V.S.'s compulsive

behaviour is intentional and voluntary, unlike tics.

Other compulsive disorders: No paraphilias, gambling or substance use history present.

 TREATMENT PLAN

Session 1: Establishing Rapport and Psychoeducation on the disorder and it's

management

Objectives:

●​ Build a strong therapeutic alliance with V.S..

●​ Provide comprehensive psychoeducation on obsessive-compulsive disorder, including

symptoms, causes, and treatment.

●​ Foster insight into the importance of treatment adherence, including medication and

therapy.

●​ Address V.S.’s concerns and misconceptions about his condition.

●​ Encourage openness in sharing thoughts and emotions.

Activities:

●​ Introduce self and discuss the purpose of therapy sessions.

●​ Engage in a discussion about V.S.’s experiences, beliefs, and attitudes regarding his

hospital stay and his diagnosis.

●​ Explain OCD in a structured manner, by incorporating visual aids or handouts- by

building on examples that V.S. mentioned in the previous discussion.

●​ Discuss the role of medication and psychotherapy in recovery and explain how

regular medicine consumption and therapy sessions might help him.

●​ Address any stigma-related concerns that V.S. may have regarding mental health

treatment.

●​ Encourage V.S. to set personal therapy goals to motivate him throughout the process

of therapy.
Expected Outcomes:

●​ V.S. demonstrates a basic understanding of his diagnosis, symptoms, and treatment.

●​ V.S. expresses willingness to actively participate in therapy.

●​ V.S. articulates the significance of medication adherence.

●​ V.S. verbalizes at least one personal goal for therapy.

Session 2: Identifying Triggers, Emotional Regulation and Coping Strategies

Objectives:

●​ Identify specific triggers that lead to these intrusive thoughts, emotional distress, and

self-muttering behaviors.

●​ Develop adaptive coping strategies to manage distress when seeing faces.

●​ Introduce and practice mindfulness techniques to improve focus and emotional

regulation.

●​ Encourage self-monitoring of symptoms and behavioral patterns.

●​ Improve emotional awareness and subsequent impulse control.

Activities:

●​ Use a structured worksheet to map out potential triggers (e.g., social interactions,

stressors, environmental factors).

●​ Guide V.S. through relaxation techniques, including deep breathing and progressive

muscle relaxation.

●​ Teach cognitive restructuring methods to challenge and reframe intrusive thoughts.

●​ Introduce the STOPP technique (Stop, Take a breath, Observe, Pull back, Proceed) to

distance from the triggering situation as a means of impulse control.

 ●​ Introduce grounding techniques (e.g., the 5-4-3-2-1 sensory method) to manage

distressing experiences.

●​ Develop a personalized coping plan incorporating distraction techniques, mindfulness,

and positive self-talk.

●​ Assign homework: Maintain a symptom journal to track triggers, emotional

responses, and coping strategies used.

Outcomes:

●​ V.S. identifies and articulates personal triggers and stressors.

●​ V.S. demonstrates the ability to implement some level of emotional regulation and at

least two new coping strategies.

●​ V.S. reports a reduction in distress after practicing mindfulness techniques.

●​ V.S. starts recognizing early warning signs of distress and implements the techniques

learnt.

Session 3: Enhancing Social and Occupational Skills and initiating relapse prevention

Objectives:

●​ Strengthen interpersonal communication and social interaction skills.

●​ Discuss future working opportunities/possibilities and enhance V.S.’s confidence in

workplace readiness and future employment.

●​ Encourage structured engagement in social activities, and discuss creating a strong

support system to rely on.

●​ Identify early warning signs of relapse and strategies for early intervention.

●​ Reinforce self-care practices and ongoing therapy adherence.

Activities:

●​ Conduct role-playing exercises simulating workplace and social interactions.

●​ Discuss and address V.S.’s fears regarding reintegration into the workforce, and

collaboratively develop a structured step-by-step plan for transitioning back to

employment.

●​ Identifying community resources and social support networks that can aid in

reintegration.

●​ Collaboratively create a personalized relapse prevention plan, including coping

strategies and support contacts.

●​ Discuss and role-play scenarios for handling stressors that may lead to relapse an

reinforce the importance of continued medication adherence and booster sessions.

●​ Conclude with a summary of progress, key takeaways, and a roadmap for long-term

recovery.

Outcomes:

●​ V.S. reports increased confidence in engaging in social and work-related interactions.

●​ V.S. develops a realistic plan for re-entering the workforce.

●​ V.S. expresses motivation to maintain social connections.

●​ V.S. verbalizes understanding of relapse prevention strategies and their importance.

●​ He demonstrates confidence in his ability to manage symptoms proactively.

●​ V.S. commits to continued engagement in therapy, medication, and self-care, and

expresses optimism and motivation for long-term recovery.

 CASE 2

CASE HISTORY

Name: R.P.

Age: 37

Date of Birth: 9 June, 1987

Sex: Male

Education: Claims to have completed TYBCOM, CS, CA, MBA, CP, CW

Occupation: Claims to currently be a PSI, formerly used to work as a junior associate (CA)

at BMP Paribhas (since 2014) and Dipesh Thakkar and Associates before that

COMPLAINTS AND THEIR DURATION

R.P. reports to be admitted to RMH as a part of his training process for IPS certifications by

his team members in the police force. He claims he should've been in the hospital only for 5

months as per the mandate, but now it's been more than 10 months since he has been

admitted. He also reports not liking the food in the hospital as a reason to dislike eating here.

HISTORY OF PRESENT ILLNESS

R.P. was diagnosed with Mania with psychotic symptoms on October 19, 2023. According to

hospital records, he was brought in by the police on October 18, 2023, after being found

roaming the streets naked. The hospital’s nursing staff reported a possible family history of

mental illness, stating that his father may have had Dissociative Identity Disorder (DID),

previously known as Split Personality Disorder, as suggested by a psychiatric social worker.

During conversations with R.P. over four consecutive days, he reported experiencing auditory

hallucinations, which he referred to as “telepathy.” He claimed that he not only heard voices

but also spoke to them regularly, having full conversations and seeking their guidance. He

mentioned that these voices belonged to his elders, well-wishers, and a Guruji, whom he

initially described as a father figure but later referred to as a maternal uncle. These voices, he

said, advised him to be patient, guided him academically, and even helped him strategize

about how to "get out of this mess," referring to his extended stay in the hospital.

On the second day of assessment, R.P. appeared slightly irritable. When asked about it, he

explained that he had received news the previous night—through telepathy—that his Guruji

had passed away, which had deeply upset him. He insisted that he needed to visit the grave.

Upon further questioning, he admitted that he had never met this Guruji in person, having

only discovered him on YouTube and television in 2008. He identified the Guruji as “Satya

Sai” and claimed that even after his death, they continued to communicate telepathically.

Additionally, R.P. alleged that a male staff member from his hospital ward (M18) was

responsible for killing Guruji. However, he mentioned that although the police investigated

the matter, no evidence was found.

R.P. also reported that his other well-wishers frequently communicated with him. He stated

that his first telepathic experience occurred between 2007-2008, initially making him feel

threatened as if someone was trying to scare him. However, over time, he began to enjoy

these voices, expressing a strong desire to maintain this connection. Additionally, he claimed

that his earliest telepathic experience happened at the age of four, describing it as “catching

waves” to establish a connection.

Alongside hallucinations, overvalued ideas of self and delusions were also present. He

claimed to have cleared exams for IAS, IPS, CFA and CPW, CW and MBA. He stated that he
is a PSI and one of his colleagues brought him in due to a mandate that all PSIs should spend

5 months at a mental care facility. He expressed frustration that he has been here for over 10

months but still hasn’t been released (even when he offered to pay the hospital

administration). However he claimed that his fellow police inspectors still came to the facility

from time to time to get his approvals and signatures on things. When inquired about how

would he pay the hospital staff, he claimed that he was extremely rich and earned more than 1

crore rupees, and he said that his family was rich too, thanks to him. He claimed initially that

his family was rich due to agricultural pursuits, but later said that they actually owned a gold

mining business, operated out of their land in Santacruz (which originally belonged to his

grandmother on his dad’s side). He claimed that his accounts are in SBI, IDBI and Bharat

Cooperative Banks and that he is exempt from tax, due to guidance from his former boss. He

also claimed to have been in several magazines and newspapers frequently (like the Times

Magazine). He further claimed to be a deity, i.e “Shri Krishna” himself (after he turned to

reading religious scriptures). As Shri Krishna, he has magical powers, especially

materialization (he can turn anything into jewellery). He further claimed to have gotten

married 11 times till date, and he went on to say that as Shri Krishna himself, he was allowed

to have 16008 wives, which is why he indulges in polygamy. He claimed to be Shahrukh

Khan’s son-in-law, and that he is married to 3 of his daughters, Suhana, Suhanika, Suhamina,

but does not have any kids with them as they are impotent and infertile. He also said that

powerful people like wizards, magicians and Sai Baba can hear his thoughts, steal his ideas

and control his mind. When asked to give an example, he said that IPL was originally his

idea, but someone stole it and never gave him credit. He also claimed to have a twin brother,

who he’s only met briefly, who is currently in the UK. He said that the reason why his parents

never introduced them in his childhood and kept them separate is because they wanted to see

which one out of the two would be more successful in life. His twin allegedly looks exactly
like him and has the same educational qualifications and achievements. Later, he claimed to

actually be a triplet, and that his third brother (also allegedly same in looks and

qualifications) was currently in Basuri. According to him, all 3 of them are the deity

“Krishna” and possess magical abilities (which is the only proof of being a god.) He also said

that his children possess (through him) magical abilities and can practice materialization. He

said they live with his wife and mother-in-law at Urbania (Thane) in flat 2808. He reports

having completed more than 78 lakh courses globally since his graduation.

Onset: Approximately 2007 to 2008. He claims that his first “telepathy” experiences

increased around that time. However he mentions 1 isolated instance of hearing telepathy at

age 4.

Course of the Illness: Continuous

Associated Disturbances: Reports sleep disturbances- that he could not sleep well before

and even now his sleep is not sound or continuous, and that it breaks in between. He further

reported anger outbursts, irritability, agitation, and self talk behaviour. He also reported not

eating his fill due to poor quality of hospital meals.

Treatment: He is given 3 tablets each day (Haloperidol 5mg, Oleanz 10mg, Diva 5mg). He

was also initially given mood stabilizers (Sodium Valporate 500mg) but it was discontinued.

He is given injections (Phenargan 50mg and Sernac 5mg). According to the ward staff, he

was also administered ECT on multiple occassions, but no significant progress has been seen.
PAST HISTORY

Reports undergoing an endoscopy for a crooked nose (due to which he had difficulty

breathing) around 2013/14. He claimed to also have sought mental consultation from Dr

Pradnya Rane, a psychologist in Mulund, who also conducted some assessments on him. He

also claimed to have a “trauma” owing to a near death accident near the eastern express

highway (Mulund) when he was allegedly travelling with a friend.

FAMILY HISTORY

Reports having a mother (58) and a father (70) and 3 sisters, Rashmi (35), and 2 twin

sisters-Deepika and Dipika (32). He also claims to have a twin brother (37), who he met just

last year and is currently in the UK. He reports having met his family last more than 10

months ago. R.P. initially reported that his family is rich because of an occupation in

farming. However, later he reported that his family is rich because they have a gold mining

business in Santacruz, which is on land owned by his grandmother. According to him, his

family separated him and his twin brother to check who between them would be better in

studies and in achieving success. He claims that he and his brother are the same in all levels

including looks, intellectually, studies and in achieving success. He reports to be in a good

relationship with his family. He later reported of not getting along with his younger sisters,

and not being able to trust them because he perceives them as incompetent. A letter also

revealed not having a good relationship with his father (who has DID) and that his father

consumes alcohol.
R.P. reported being married to Rashmi Bhanushali in 2010, claiming that she works in

another ward at RMH and has completed CA Intermediate. He states that they have six

children, namely Purab, Paschim, Uttar, Dakshin, Kendra Bindu, and Bindu Kendra. He

claims that all of them are six years old and look exactly identical. However, he is unable to

recall their birth dates. According to him, his wife chose their names, which he also likes.

However, when nurses inquired about his family history, they revealed that just days before

the assessment, he had reported having only four children—Uttar, Dakshin, Purab, and

Paschim. Additionally, he later claimed to have 11 wives, three of whom he believes are the

daughters of Bollywood actor Shah Rukh Khan. He also asserts that he gets married to every

woman he meets.

PERSONAL HISTORY

●​ Birth and early development: Reports as normal and age appropriate

●​ Behaviour during childhood: Reports normal, with no difficulties. Reports that his

day primarily consisted of going to school and playing with his friends.

●​ Physical illnesses during childhood: None. Reports to bounce back from common

colds normally.

●​ School: R.P. initially lived in Mulund, where he completed his schooling, and is

currently residing in Murbad. He also claims to own multiple houses and lands across

Mumbai. He reports enjoying school and describes himself as a high achiever, stating

that he was a rank-holder and performed well academically. However, he also recalls

getting into fights and being punished by teachers for causing disturbances. He

mentions attending St. Pius School and later MCC College in Mulund, where he
 studied Commerce (BCOM). He claims to have scored 89.3% in his 10th-grade exams

and 87.5% in his 12th-grade exams. Additionally, he reports clearing CA, CS, and

MBA exams and attending coaching classes such as MT and Sancheet. However, he

later contradicted his earlier statements, saying that he actually attended Holy Angels

School. Regarding his college performance, he claims to have scored approximately

82% in his first and second years, but his marks dropped to 67% in his final year,

which he attributes to an illness. He further said that he never stopped studying till he

became an IPS officer, and that since his graduation he has completed more than 78

lakhs courses since his graduation.

●​ Occupation: R.P. reports that he used to work as an Associate as a CA and that he has

3 years of experience as a CA. He claims to earn more than 1 crore rupees as his

monthly income and has his money deposited in SBI, IDBI and Bharat Cooperative

banks. He also claims he has been exempted from paying taxes after going through

some paperwork for it. He claims that he was guided into the tax exemption by his

former boss, who had also helped his other colleagues. He also has a stake in the

family business, which he claimed initially to be agriculture, and later to be gold

mining. He takes credit for his family being rich.

●​ Menstrual history: Not applicable

●​ Sexual history: R.P. reports engaging in sexual intercourse prior to admission in

RMH. He claims to have had sex since 2014. He also reports engaging in romantic

pursuits (including sexual activities) with more than a dozen women who he is still in

contact with.

●​ Marital history: He reported being married to Rashmi Bhanushali in 2010, with

whom he has 6 kids. He and his wife do not live together, as his wife allegedly

expressed her wish to be closer to her parents.

 ●​ Use and abuse of alcohol, tobacco and drugs: Denies consumption of substances, as

it is not allowed for IPS duty.

NEGATIVE HISTORY

Does not consume any substances and no major injuries or surgeries.

PREMORBID PERSONALITY

●​ Attitudes to others in social, family and sexual relationships: R.P. perceives that

all around him are his well wishers.

●​ Attitudes to self: R.P. views himself as Krishna and that others also view him as

Krishna.

●​ Moral and religious attitudes and standards: R.P. reports to be very religious.

Practices Hinduism. He also claims to be a deity himself, Lord Krishna.

●​ Mood: Elated.

●​ Leisure activities and interests: R.P. reports to like watching movies and TV,

playing PC video games, playing carom, chess and table tennis.

●​ Fantasy life: He wants to visit Sri Lanka.

●​ Reaction pattern to stress: Walking and dealing with it.

●​ Habits: Used to have problems with sleep. Reports no appetite or bowel problems.
A DAY IN THEIR LIFE

Ordinarily, he wakes up early for breakfast and medications, engages in physical exercise

along with other inmates from his ward and then either talks to the nurses (for routine checks)

or spends his time resting. It was noticed that he strolls around in his ward a lot and does not

often talk to the other inmates.

COPING STYLES

Avoidant
 MENTAL STATUS EXAMINATION (MSE)

GENERAL BEHAVIOUR

R.P. appeared to be neat, well groomed and hygienic, however some drooling was observed,

which was discovered to be a side-effect of his medication. He was conscious,

comprehensive and attentive. He maintained eye contact throughout the session. He was

slightly restless, fidgety and agitated. At times, he was also irritated and on numerous

occasions shifted his seat between the two beds. He was drooling a bit which can be

attributed as a side effect to his medications. Rapport was established and he was interactive

during the session.

PSYCHOMOTOR ACTIVITY

Slightly increased, agitation, constant fidgeting and strolling

TALK

Amount of speech: Expansive

Tone: Normal

Tempo: Normal​

Reaction Time: Normal

Speech coherent, relevant and responds to questions, sometimes redundant.

MOOD

Elated Mood and Congruent Affect.

THOUGHT

●​ Absence of flight of ideas, retardation of thinking, circumstantiality, preservation,

thought blocking.

●​ Presence of formal thought disorder

●​ Absence of obsessions and compulsions, thought alienation.

●​ Presence of delusions.

CONTENT

R.P. exhibits a variety of delusional beliefs, including grandiose, religious, and reference.

Those that were brought up during the course of assessment were:

●​ He firmly believes he has successfully cleared multiple competitive exams (e.g., IAS,

IPS, CFA) and holds prestigious roles such as PSI, despite clear evidence to the

contrary.

●​ He perceives himself as extremely wealthy, which he earlier attributed to family

ventures in agriculture and gold mining, but later claimed an income exceeding 1

crore rupees monthly from his job

●​ His religious delusions include identifying himself as a deity, "Shri Krishna," and

asserting that he possesses magical abilities, such as materialization.

●​ He rationalizes polygamous beliefs through religious justifications, claiming to have

11 wives, including fictional individuals like the daughters of actor Shahrukh Khan.

●​ He experiences delusions of reference, believing that powerful figures, such as

wizards and Sai Baba, can control his mind and steal his ideas. He asserts that the IPL

was his original concept.

●​ He also reports a bizarre identity distortion, claiming to have a twin or triplet who

shares his identity and achievements.

 ●​ His sense of self-importance is highly inflated, often expressing frustration over his

prolonged hospitalization.

There were no signs of excessive worries or preoccupations, no hypochondriacal or somatic

concerns and no evidence of depressive thoughts, feelings of worthlessness, guilt,

hopelessness, or suicidal ideation.

PERCEPTION

●​ R.P. reports experiencing auditory hallucinations, which he believes to be “telepathy”

and that these voices first appeared between 2008 and 2010, initially frightening him,

as he thought they intended to harm him, but he later became comfortable with it. He

also reported that in an attempt to understand these experiences, he began studying

religious texts, which led him to believe that he was an incarnation of Krishna.

●​ He believes these voices belong to his ‘well-wishers’, including his parents, uncles,

and other elders and that the voices began offering guidance and advice, particularly

on how to study and achieve success. He claims to have followed their instructions

and appreciates their presence, enjoying both listening and conversing with them.

●​ R.P. also describes hearing the voice of a spiritual figure, ‘Guruji,’ who he believes

communicates with him telepathically. He states that he first encountered Guruji

through YouTube videos during his college years and, despite never meeting him in

person, believes he developed a telepathic connection with him.

●​ He claims that he received news of Guruji’s passing a day before it was publicly

known, through telepathic means. He expressed sadness over Guruji’s death and a

desire to attend his funeral.

COGNITIVE FUNCTIONS

●​ Attention and concentration: Intact

○​ Serial Subtraction: 93, 87, 81, 72

●​ Orientation:

○​ Name: R.P. Manohar

○​ Place: RMH

○​ Date: 24/12/2024

○​ Time answered: Around 12pm, Actual time: 11

●​ Memory:

○​ Immediate Memory: Intact

○​ Recent Memory: Intact

■​ Food last night- chapati, rice, daal

○​ Remote Memory: Intact

■​ Personal childhood event: Birthday, gave away chocolates in school.

○​ Recall: Intact

■​ Presented 3 words (blue, banana, cow) and asked to recall after some

time.

●​ General information: Appropriate

○​ Name of the Prime Minister: N. Modi

○​ Major cities in India: Mumbai, Pune, Surat, Agartala, Bhandara

●​ Intelligence: Appropriate. Highly efficient and fluent in English, Hindi and Marathi.
●​ Abstractibility: Appropriate

○​ Find Similarities:

Table, Chair - Furnitures, to keep things

Fruits- Orange, Banana

○​ Meaning of Proverb: Answered Correctly

1) Naach na jaane aangan teda

2) Bagal mai chora sheher mai dhindora

3) Kangali mai aata geela

●​ Judgement: Partially Impaired

(a) Personal Judgement: Impaired (Initially he thought he had a split

personality, but nurses told him it was schizophrenia so he agreed with that)

(b) Social Judgement: Impaired (If 2 people are fighting what should be done?

Police are allowed to intervene, they come after the fight is done.)

(c) Test Judgement: Intact (What would you do if a stamped, sealed, addressed

envelope is found in the street? - Put it in the post box, give it to the postman,

give it to the post office.)

●​ Insight: Level 3 Insight. Aware of being sick but blaming it on others.

 CLINICAL ASSESSMENTS

Tests Conducted

Sentence Completion Test (SCT)

Millon Clinical Multiaxial Inventory III (MCMI 3)

SENTENCE COMPLETION TEST (SCT)

The Sentence Completion Test (SCT) by Dr. Govind Tiwari is a projective psychological tool

used to assess an individual's personality, thoughts, emotions, and underlying attitudes. It

requires respondents to complete a series of incomplete sentences, allowing for free

expression and revealing subconscious aspects of their personality. It is a projective test and

often gives more insight into their thoughts and feelings regarding themselves, their

family/friends/community and their general view of their life. R.P. was able to understand

the instructions and items with minimum clarification and was cooperative and willing to

participate in the testing process.

It is observed that R.P. may tend to rely on validation from external sources to feel successful

or happy. It is noted that he may have a high and positive self concept, and that he tends to

view his childhood as important and perceives himself to be good at everything he does. It is

observed that he has high standards that he has set for himself and reports feeling angry when

he does not meet them. However, he reports achieving a lot of success in his life, and has a

tendency to view his life as “fulfilled” and worthwhile, and reports being satisfied with it. He

says that his dreams often come true and that he has achieved everything he wants. He reports

to not being bothered by illness/health concerns. It also observed that he may tend to get
worried by troublesome situations and may tend to avoid looking at past failures. At the

same time he claims to be curious to know more about himself. He reports that he often feels

“on top of the world” and that his biggest ambition is to “rule the world.”

It is reported that he may tend to have a complex relationship with others wherein he

sometimes views others as his well-wishes and that others know him well but also reports

that others often underestimate him and are jealous of him and take credit for his work. He

also reports having a tendency to look down on others as they are not on the same level as

him. He claims to have a good relationship with his parents and that he is loved by them, but

also reports not having a good relationship with his father. He also reports his parents not

coming to meet him. He also reports fearing that his mother is sick or hurt, but overall tends

to avoid talking about his family a lot. He further reports that he believes that it is good to

have as many friends as possible. He perceives that those around him tend to know him well.

It is observed that he believes talking ill behind people’s back is bad. He also views quarrels

as unnecessary and tries to sort out any quarrels. He also reports being nice to only those who

are nice to him, and that he hates individuals who talk back to him or swear at him. He

supports this by saying that he likes to see people as obedient and trustworthy. He also says

that people don’t always believe him.

He believes that time should always be spent productively, and that people should view their

pasts as a good lesson for their future. He views the laws of the government to be fair and

equal for everyone, saying that it is true and trustworthy. Furthermore, he says that finances

are very important in life, saying that life is pleasant when one is rich, and that employment is

necessary for everyone. Furthermore, he believes god to be great and religion as important.
 MILLON CLINICAL MULTIAXIAL INVENTORY III (MCMI-3)

The Millon Clinical Multiaxial Inventory- III is a psychological test used to assess the

presence and severity of personality and symptom disorders in adults. It is usually used with

the clinical population (people who are undergoing psychodiagnostic evaluation or

psychotherapy) to investigate personality traits, disorders, symptoms and their severity. It is

an objective test containing 175 items with a dichotomous responding pattern (true and false),

and takes approximately 30 minutes to administer. This assessment was conducted with R.P.

in English. He was able to understand the items with minimum clarification and was initially

hesitant but later cooperative and willing to participate in the testing process.

R.P.’s responses on the Millon Clinical Multiaxial Inventory-III (MCMI-III) suggest a

questionable profile (Scale V), indicating that he may not have responded entirely accurately.

As a result, the findings should be interpreted with caution. However, his high score on the

Disclosure Index suggests that he was open, frank, and self-revealing in his responses.

Adjustments were made to his Base Rate (BR) scores to account for potential response

biases.

R.P.’s scores were elevated on the avoidant scale which indicates heightened sensitivity to

rejection, often anticipating negative evaluations. He may exhibit social withdrawal due to

fear of disapproval, despite an underlying desire for social connection. His main defense

mechanism appears to be fantasy, as reflected in his overvalued ideas and delusions.

He may rely heavily on others for emotional support, guidance, and reassurance as indicated

by an elevation of his scores on the dependent scale. He likely seeks relationships that
provide security and protection, has a pacifying temperament, and avoids conflict whenever

possible.

R.P. exhibits self-centeredness, a need for admiration, and an expectation of special

treatment, which can be seen in his scores for narcissism. He may appear arrogant, boastful,

and entitled, and he might exploit social relationships for personal gain. While he can be

momentarily charming, he may also be socially imperturbable. If he experiences narcissistic

injury, he may be prone to affective disturbances or even paranoia.

R.P. also exhibits self-defeating tendencies, and his behaviour may have a pattern of allowing

others to take advantage of him. He tends to adopt a self-sacrificing and martyr-like role in

relationships, seeking security and affection in return. This trait suggests a tendency toward

victimization.

His scores further indicate extreme paranoia, which might manifest as being highly

mistrustful, often believing that others are trying to control or harm him. He can be abrasive,

irritable, and hostile, and he may react with belligerence if provoked. His rigid thinking and

argumentative nature may be reinforced by delusions of grandeur, persecution, or ideas of

reference. His primary defense mechanism appears to be projection.

Scores indicate that R.P. is frequently anxious, restless, and unable to relax. He may

experience physical symptoms such as insomnia, muscle tightness, headaches, nausea,

excessive sweating, cold hands, and heart palpitations.

His mood is likely to be highly unstable, with frequent emotional fluctuations. During manic

episodes, he may exhibit flight of ideas, pressured speech, impulsivity, unrealistic goals, and

an excessive need for interpersonal engagement. His elevated scores suggest potential

psychotic features, including hallucinations and delusions.

Furthermore, he may experience grandiose or persecutory delusions, leading to

hypervigilance, hostility, and suspicion. He might perceive threats where none exist, react

belligerently, and have irrational thoughts of being controlled or influenced by external

forces.

To conclude, R.P.’s MCMI scores indicate elevated traits of avoidant, dependent, narcissistic,

paranoid, and self-defeating personality features. He appears hypersensitive to rejection,

socially withdrawn, yet seeks emotional support. His self-centered tendencies make him

crave admiration and special recognition, though he may also manipulate social interactions

for personal benefit. He exhibits high anxiety, mood instability, and potential delusional

thinking, including persecutory and grandiose beliefs. Additionally, he may have a tendency

to be taken advantage of, contributing to a self-defeating and victimized behavioral pattern.

These findings are in line with his case history and provide better insight into the way his

personality manifests.
 CASE FORMULATION

For the purpose of better understanding this case, we can conceptualize it using the 4P model,

which talks about 4 kinds of factors to understand the causes behind the development and

maintenance of a disorder.

Predisposing Factors: These are factors that make a person more vulnerable to developing

an illness. Upon speaking to R.P., it was found that there is a history of mental illness in

R.P.’s family. He stated that his father has “split personality disorder” (also known as

Disassociative Identity Disorder). Additionally, R.P. also reported that his father was a regular

and heavy consumer of alcohol.

Precipitating Factors: These are what are assumed to be the “triggers” or the reason for

the manifestation of the illness. In R.P.’s case, the precipitating factors could be hypothesized

academic failure (as characterized by “feeling” lost after graduation, scoring very less in his

final year, possibly not clearing his CA attempt.) Upon conversation with him, it was found

that academics was of major importance in his life, to feel successful, which could also help

explain why a lot of his delusions are surrounding academic achievements. Another

precipitating factor could also be an unsuccessful romantic pursuit (as he mentioned having

strong feelings for 2 girls named Mamta and Rashmi during college. He mentioned being

friends with both of them but then said that he was rejected by both of them during his

college days. Later, he mentioned that he ended up getting married to Rashmi in 2010, after

she apologized to him for rejecting him.) This could explain his inconsistencies with his

marital history and his desire to have 16,008 wives.

Perpetuating Factors: These factors are what could primarily help us understand the reason

why the disorder is persisting or “being maintained”. In R.P.’s case, it was found that he

lacks insight. As per his testimony along with information from the ward staff and nurses, it

was also found that he has not had any visits from any person throughout the duration of his

stay at the mental hospital. Furthermore, R.P. also reported not having a good relationship

with his father, stating that he was very strict and at times neglectful, causing them to not

speak to each other for a couple of years (even before his admission.) In his file, there was an

attached copy of his father’s e-mail to the sister-in-charge of the hospital, requesting delay of

his discharge, dated to November of 2023 (as father was himself experiencing health and

financial concerns), further evidencing the strained relationship. R.P. also reported frequent

fights and conflicts with his father. Alongside, R.P. mentioned having friends, a mother and

his sisters (whom he reports as being incompetent and incapable), but none of them came to

visit him, and that he does not talk to most of his friends and only stays in touch through

facebook. These hypothesized conflicts, strained relationships, perceived abandonment and

lack of support system could be some of the perpetuating factors to understand this case. It

could also help understand why some of his hallucinations are of his father, mother or

father-like figures (ex; Guruji) and why he likes having this alleged “connection.” Another

factor could be low socio-economic status (as presumed through his father's e-mail) which

could have prevented him from seeking appropriate help, care and resources during the initial

phase of his illness. This could also explain why he might have a delusion of

over-exaggerating his financial condition (“calling himself rich”.)

Protective Factors: These are mechanisms that reduce or prevent the occurrence of a mental

disorder, or could help a person through treatment (as an aid or a goal to work towards.)

Although there is a clear lack of effective protective factors in R.P.’s case, we can presume
his intellectual prowess, positive self-esteem and sense of worth, hope for the future and

belief in spirituality to be some possible aids/lifelines through the course of his treatment.
 PROVISIONAL DIAGNOSIS

The provisional diagnosis for R.P. is of Schizoaffective Disorder: Bipolar type can be given

to R.P. according to the DSM 5 tr criteria.

A. An uninterrupted period of illness during which there is a major mood episode (major

depressive or manic) concurrent with Criterion A of schizophrenia.

R.P. exhibits symptoms that meet Criterion A for schizophrenia, including auditory

hallucinations and delusions, which occur alongside a manic episode. He experiences a

distinct period of consistently elevated, expansive, or irritable mood that lasts for at least one

week and is present most of the day, nearly every day (or for any duration if hospitalization is

required). His symptoms include inflated self-esteem and grandiosity, increased talkativeness,

a subjective sense of racing thoughts, distractibility, and psychomotor agitation. The severity

of his mood disturbance significantly impairs his social and occupational functioning or

requires hospitalization to prevent harm to himself or others. Additionally, his condition

includes psychotic features.

B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode

(depressive or manic) during the lifetime duration of the illness.

R.P. reported delusions as well as hallucinations for at least 2 weeks even in the absence of

depressive or manic episodes.

C. Symptoms that meet criteria for a major mood episode are present for the majority of the

total duration of the active and residual portions of the illness.

In R.P.’s case, manic episodes are dominating and accompanying the presentation of his

illness but do not explain all the psychotic features.

D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a

medication) or another medical condition.

There is no reported history of another medical condition or consumption of any substances.

Specify: Bipolar type

Differential Diagnosis:

Psychotic disorder due to other mental disorders or medical conditions: Absence of

symptoms attributed to other mental disorders/ medical conditions.

Schizophrenia: mood symptoms are absent or present for a relatively brief period compared

to the psychotic symptoms. Schizoaffective disorder requires prominent mood episodes for a

significant portion of the illness.

Bipolar I: psychotic symptoms occur only during mood episodes, whereas in schizoaffective

disorder, psychosis persists in the absence of mood symptoms for at least 2 weeks.

Delusional disorder, the psychotic symptoms are limited to delusions without other

schizophrenia-spectrum symptoms such as disorganized behavior or hallucinations.

 TREATMENT PLAN

Session 1: Establishing Trust, Relaxation, and Emotional Awareness

Objectives:

●​ The primary goal of this session is to build a strong therapeutic alliance and create a

safe space for R.P. to open up.

●​ R.P. will learn relaxation and grounding techniques to manage agitation, anxiety, and

stress.

●​ He will begin exploring and understanding his emotions, along with the connection

between his thoughts, feelings, and behaviors.

Steps:

●​ The therapist will use reflective listening to ensure R.P. feels heard and understood,

fostering trust in the therapeutic process.

●​ As R.P. shares his concerns, particularly about his symptoms (e.g., delusions), the

therapist will normalize his experiences in a supportive way to reduce feelings of

isolation.

●​ Relaxation techniques such as deep breathing exercises and Jacobson’s Progressive

Muscle Relaxation (JPMR) will be introduced and practiced to help R.P. manage

physical tension and stress.

●​ Grounding techniques, such as tracing the outline of his hand or counting backward,

will be taught to help him stay present and reduce agitation.

●​ The therapist will introduce an emotion wheel, asking R.P. to identify emotions that

resonate with him and explain why.

 ●​ R.P. will be guided to reflect on a recent emotionally triggering situation and explore

how his emotions influenced his thoughts and behaviors.

●​ To encourage self-awareness, he will be introduced to a thought-emotion log, where

he will track daily emotions and associated thoughts.

Outcomes:

●​ R.P. will feel more at ease with the therapist and develop initial trust in the therapeutic

process.

●​ He will begin to see his emotions as natural and valid, reducing self-judgment.

●​ He will successfully learn and practice relaxation and grounding techniques both

in-session and independently.

●​ By tracking his thoughts and emotions, R.P. will start recognizing emotional triggers

and patterns in his reactions.

Session 2: Psychoeducation, Self-Regulation, and Behavioral Activation

Objectives:

●​ R.P. will gain a clear understanding of his diagnosis (Schizoaffective Disorder,

Bipolar Type) and the rationale behind his treatment plan.

●​ He will recognize the importance of medication adherence and how it helps manage

symptoms.

●​ He will learn the significance of self-regulation strategies, particularly maintaining

proper sleep and appetite hygiene.

●​ He will be introduced to behavioral activation, helping him engage in meaningful

activities to improve his mood and motivation.

Steps:

●​ The therapist will explain R.P.’s diagnosis in simple, non-technical language,

emphasizing the relationship between mood disturbances and psychotic symptoms.

●​ The role of medication (Haloperidol, Oleanz, Diva) will be discussed, including its

benefits, expected effects, and the importance of adherence for relapse prevention.

●​ R.P. will be encouraged to ask questions and express any concerns about his diagnosis

or treatment plan.

●​ The therapist will review self-regulation techniques, including previously learned

relaxation methods, and introduce the importance of consistent sleep and balanced

nutrition in stabilizing mood and reducing symptoms.

●​ The concept of behavioral activation will be introduced to help R.P. re-engage in life

through structured activities that provide pleasure, productivity, and a sense of

mastery.

●​ Together, the therapist and R.P. will:

○​ Identify small pleasurable activities (e.g., listening to music, playing board

games) to add joy to his routine.

○​ Discuss productive tasks (e.g., completing small academic or household

responsibilities) to foster a sense of accomplishment.

○​ Explore mastery-building activities (e.g., developing a new skill or working on

a personal project) to boost confidence and self-efficacy.

●​ A structured but flexible weekly schedule will be developed to ensure these activities

are incorporated into his daily life.

Outcomes:

●​ R.P. will gain a basic understanding of his illness, reducing misconceptions about his

symptoms.

●​ He will recognize the importance of medication adherence in managing his condition.

●​ He will begin to maintain better sleep and appetite hygiene, contributing to overall

stability.

●​ He will start to engage in pleasurable, productive, and mastery-driven activities,

helping him regain motivation and a sense of purpose.

Session 3: Building Social Skills, Communication, and Support Networks

Objectives:

●​ R.P. will improve his ability to communicate effectively in various social situations.

●​ He will develop confidence in navigating conversations, especially when discussing

sensitive topics like his symptoms.

●​ He will be encouraged to reduce social isolation by engaging in a support group or

group therapy to enhance his recovery and social well-being.

Steps:

●​ The therapist will introduce social skills training, focusing on essential skills such as:

○​ Maintaining eye contact to show engagement in conversations.

○​ Practicing active listening, ensuring he understands and responds

appropriately to others.

○​ Developing assertiveness, helping him express his thoughts and feelings

respectfully.
 ●​ Role-playing exercises will be conducted to help R.P. practice different social

scenarios, such as:

○​ Interacting with family members.

○​ Communicating with healthcare providers.

○​ Engaging in conversations with peers or friends.

●​ Strategies will be introduced to help R.P. manage frustration and irritability in social

interactions, particularly when others misunderstand or challenge his experiences.

●​ The therapist will guide R.P. in identifying and expressing his emotions appropriately,

helping him strengthen emotional intelligence and social awareness.

●​ R.P. will learn to recognize social cues and adjust his responses accordingly,

improving the quality of his interactions.

●​ The therapist will encourage R.P. to join a support group or group therapy, where he

can share experiences, receive validation, and develop social connections in a

structured setting.

Outcomes:

●​ R.P. will demonstrate improved communication skills, including active listening,

setting boundaries, and articulating his thoughts more effectively.

●​ He will gain confidence in social interactions through both role-play and real-life

practice.

●​ He will learn strategies to manage frustration when discussing sensitive topics,

leading to healthier social interactions.

●​ He will show greater emotional awareness, expressing his feelings in appropriate

ways and responding empathetically to others.

●​ By engaging in a support group or group therapy, he will experience a reduction in

social isolation and begin to build meaningful social connections.

 CASE 3

CASE HISTORY

Name: PM

Age: 49

Date of Birth: 18/08/1975

Date of Assessment: 06/01/2025

Sex: Female

Education: BCOM

Occupation: Currently a housewife. Used to work a desk job at a marketing firm in Malad

COMPLAINTS AND THEIR DURATION

P.M. reports distress over being falsely admitted in the hospital by her husband under the

false pretence of taking her to her brother's home. She reports being hit by her husband and

getting into fights with him over her cooking. She also reports being hit by her son. She

complained about body pain, especially pain in back and knees, for a few weeks. She reports

increased need to sleep and decline in appetite. She also complains about the hygiene in her

hospital ward which she says to be filthy and lice ridden. She also reported that she suspects

that her family wishes to get rid of her.

HISTORY OF PRESENT ILLNESS

P.M. was admitted to RMH on 28/12/24 where she was given the diagnosis of Schizophrenia.

Her case files report the presence of mental illness from around 14 years (since 2011), during

which she was taken to a private psychiatrist in Santacruz. P.M. reports losing her mother

around this time.

Her case files indicate the presence of delusions of infidelity, persecutory delusions, poor self

care for her entire course of illness with symptoms like spells of excitement, auspiciousness

and aggressive behaviour being persistent for 1 month. She also reports hearing voices that

say ‘Burn Burn Burn’ (in Sindhi). She claims that these voices tell her to set things on fire or

leave the gas stove on. On one such occasion, after hearing these voices, she actually set

herself on fire (in 2018). When asked more about these voices, she says it belongs to relatives

and people who are known, and that she hears them most when she is at home alone or when

she is cooking “bolte hai ki cylinder fod de blast karde”. She said “ye log (owners of the

voices) mujhse jalte hai aur meri property hadapna chahte hai kyuki vo log khud toh kuch

kaam karte nahi hai.” Some people she recognized were her sister-in-laws, her own sisters

and her mamaji.

She also reported episodes of anger outbursts at home, where she would get distressed and

break plates and throw things around. She said “gusse mein apne aap ko maarti thi” and

reported that “kabhi vineet ya uske papa pe haath nahi uthaya.” However, she repeatedly

reports about being hit by her husband since 2011 and reports that the bruises on her upper

arm had been inflicted by her husband. She also reports being hit by her son. She also claims

that her husband doesn't let her contact her siblings. She reports having gone to the police to
file a case against her husband on multiple occasions, and that he was just left with a

warning. She reports distress, anger, resentment and hopelessness over people (the police, her

psychiatrist and the hospital doctors and staff) not believing her.

She also reports feeling extremely sleepy at most times, even prior to her admission and

medications, with a lack of energy and a disinterest in doing anything. She spent majority of

her time just eating and sleeping and did not feel like interacting with anyone or doing any

work around the house. She also said that her appetite used to fluctuate (with sometimes

being very less and sometimes a lot) and that because of this behaviour their fights at home

significantly increased, with the husband hitting her multiple times. She also claims that she

enjoys sewing and drawing but it does not give her pleasure anymore. While talking about

her interest in art, she claimed that she is in possession of a magical pencil that can draw

anything she has on her mind.

Onset: 2011- P.M. reports hearing the voices for the first time shortly after her mother’s

death (As also reported by her previous medical reports and her informant)

Course of the Illness: Gradual

Predisposing Factors: None reported, however a plausible link can be made with her

mother, who had severe anger issues and would often act as if “mata chadh gayi”

Precipitating Factors: P.M. losing her mother (who she was close to) and being physically

abused by her husband

Perpetuating Factors: Ongoing physical abuse by the father and son, no proper social

support and poor living conditions

Protective Factors: Her character traits of being hopeful and optimistic, and her fantasy life

of a good relationship with her son

Associated Disturbances: Reports increased sleep and decline in appetite and body aches

which makes her unable to do her tasks.

Treatment: P.M. is given an injection each day of Phenargan 10 mg. She also gets tablets for

antipsychotics (Lozapine, Halloperidol 5mg, Sizopen 25mg, Risden 2mg, and Ridone 13mg),

mood stabilizing agents (Carbomezapine 200mg and Clonazepam 10mg) and thyroid

medication (Pociture 2mg and Pasit).

PAST HISTORY

Reports having Thyroid. Reports going to the doctor for treatment and taking medications.

Her case files report the presence of mental illness from 14 years during which she was taken

to a private psychiatrist in Santacruz (name unknown) by her husband. She mentioned not

benefitting from the medication and shortly after discontinuing the medications by herself.

She revisited the psychiatrist in 2018 (after she tried setting herself on fire) but reported

discontinuing the medicines again,

FAMILY HISTORY

P.M. was born in a Sindhi family. She lived in a nuclear family setup with her mother (who

had a history of high blood pressure and agressive behaviour) and father (who had diabetes

and was strict) and reports having 4 siblings (one elder brother, 2 elder sisters and 1 younger

sister). She got married to Omprakash, a saree shop owner, in 2001 and had a son by the

name of Vineet in 2003 (who was born 8 days premature but had a normal delivery). It was a

match arranged by their families. She has 2 sister in laws by marriage but reports that they do

not talk or keep much in touch. She further said that the husband’s mother and father had died

way before their marriage (cause unknown) and this was one of the primary reasons why her

family got her married to him. She reports having a good relationship with her siblings in her

childhood, but says that she does not talk to her sisters now because “aise logo k muh koun

lage.” She claimed that she used to talk to her brother but her husband deleted his contact

from her phone and does not let them talk. She was overall very reluctant to talk about her

family (apart from her husband and son) saying that there is no point in talking about them.

When speaking about her husband and her marriage in general, she expressed a lot of disdain

and dissatisfaction. She claimed that getting married was the worst thing that could have

happened to her and that her life is miserable. She reports only having met her husband once

before getting married, and refers to him as “badsurat kala kutta.” She said life in the initial

years of marriage were normal, with no significant issues and that husband used to be busy at

work and come home only at nights. It was around this time that she had her son and she said

she used to raise him by herself most of the time and for the next few years spent a majority

of her time doing things with and/or for her son. However she reported that eventually

frequent fights broke out between her and her husband, where he would critique her food, her
way of doing chores, her parenting etc. P.M. reported that most fights were about food and

how he never liked what I made for him. These fights significantly worsened and her husband

eventually started getting physically abusive in 2011 after her mom’s death. She claims to

have filed a police complaint against her husband thrice. At the time of assessment, she

showed a bruise mark on her hand which she claimed was given to her by her husband. At

mentions of her husband P.M. gets visibly disturbed and she talks about him loathfully, using

statements like “uski shakal dekhi hai, kala kutta hai vo”, and “aisa pati bhagwan kisi ko na

de, isse acha toh meri shaadi hi nahi hoti.” She also said that in recent years, her son has also

started physically abusing her. When asked about how she feels when this happens, she said

that “aisi aulad paida karneki saza hai ye” and “kutto ki tarah kaam karke usko paala, yehi din

dekhne k liye”. She reports dissatissfaction and tiredness from her life and frequently thought

“aise jeene se acha khudko khatam hi kar deti hu.”

PERSONAL HISTORY

Birth and early development: Reports to be normal.

Behaviour during childhood: She reports that she did not make many friends in her

childhood and liked to stay alone.

Physical illnesses during childhood: Reported None.

School: She reports her performance in school being not good as she would just get passing

marks and claims to be not smart when it comes to studies. She completed her BCOM around

1994/1995.

Occupation: She used to give tuitions to children and also sew clothes. She reports working

a desk where she used to fill forms at a marketing firm, which was a 9-5 job.

Menstrual history: Reports that it used to be normal as she now is in menopause. Reports

not remembering the onset of menopause however approximates it to be after 35.

Sexual history: P.M. reports engaging in sexual activities with her husband after their

marriage. She reports not enjoying the sexual intercourse with her husband.

Marital history: She reports getting married on 20th May, 2001 when she was 25 years old.

She reports it being an arranged marriage. She reports she has no in-laws as her husband's

parents have passed away. She had her son in the year of 2003 when she was 27 years old,
she also reports having a normal delivery with no complications during pregnancy and

delivery.

Use and abuse of alcohol, tobacco and drugs: Denies Substance use.

NEGATIVE HISTORY

Absence of substance use, flashbacks, TBI, family psychiatric history.

PREMORBID PERSONALITY

Attitudes to others in social, family and sexual relationships: She mentioned that others

want to cause her harm and want to get rid of her because they don’t do any work and they

want her property. She further reported not enjoying sex with her husband.

Attitudes to self: She believes herself to be nice and someone who doesn’t cause fights but

people fight with her to prove that she is mad because she is someone who is “bholi.”

Moral and religious attitudes and standards: She is religious and prays regularly. She is a

follower of Hinduism and especially believes in Shri Krishna.

Mood: Depressed

Leisure activities and interests: She likes sewing, watching TV and movies and drawing.
Fantasy life: Wishes to get out of the facility and wants a day where her son will love her

and care for her.

Reaction pattern to stress: Avoidance and blaming others

Habits: Low appetite and increased sleep

A DAY IN THEIR LIFE

P.M. reports waking up early at 4:30 am after which she takes a bath, eats her breakfast, does

her daily exercise, morning prayers and takes her medications. After that she sometimes

reports watching television and rarely reports conversing with her inmates. She reports

spending most of her day sleeping. She takes her medications in the evening and sleeps

around 10:30 pm.

COPING STYLES

Aggression (as she would indulge in getting into fights, breaking plates, self harm),

avoidance (as she tends to sleep most of the time).

 MENTAL STATUS EXAMINATION (MSE)

GENERAL BEHAVIOUR

P.M. appeared to be not well groomed and slightly unhygienic. She was conscious and held

her attention. She maintained eye contact throughout the session. Adequate rapport was

established and she was cooperative during the session. However, she would feel extremely

sleepy during the session which has led to early termination of the session.

PSYCHOMOTOR ACTIVITY

Decreased

TALK

Amount of speech: Normal

Tone: Low

Tempo: Normal​

Reaction Time: Slightly low

Speech coherent, relevant and responds to questions.

THOUGHT

●​ Absence of flight of ideas, retardation of thinking, circumstantiality, preservation,

thought blocking.

●​ Presence of formal thought disorder

●​ Absence of obsessions and compulsions, thought alienation.

●​ Presence of delusions.
CONTENT

●​ She reports being worried about her physical safety “khud ko kuch karlu ya gharwale

kuch karde” and says that in addition to her husband and son hitting her she is scared

that her relatives will kill her because “unko meri property hadapni hai, vo khud toh

kuch kaam karte nahi”. She thinks everyone hates her and wants bad for her because

“they are happy when I am sad”

●​ Fears for her sanity stating that others are manipulating her “sablog mujhe jhoot bol

rahe hai. Mein pagal nahi hu, vo log hai aur vo log mujhe bol rahe hai”

●​ She reports that she has had persistent thoughts about killing herself because of the

voices and the situations at home and that she thinks “mein nahi rahungi toh sab

khush rahenge” and reported one instance of this suicidal ideation manifestation when

she set herself on fire 6-7 years ago (2018). On thet day she attempted she reports that

she was already particularly sad, and while cooking in the kitchen she heard voices

“burn burn” and in the moment she strongly felt ki “mein hi sab fasaad ki jadd hu,

mujhe zinda nahi rehna chahiye, before pouring oil on herself and lighting a

matchstick.

●​ She also experiences guilt “maine mere bete ko aise jahil k saath paala, ab mera beta

bhi vaisa hogaya hai” and blames herself for how he turned out and that if she was a

better mother things would be different.

●​ She reports that she has also always felt worthless because “meri behene mujhse aage

hai aur hoshyar hai aur bachpan mein me thi hushyar thi lekin fir bhi mein aage nahi

hui aur unka zindagi ab acha hai”

●​ She further claimed to be in possession of a set of magical pencils that could draw

anything you want by merely holding it, and that we don’t have to move at all.
Based on her case history, we can understand that her thoughts have:

●​ Presence of worries and preoccupations, and somatic symptoms.

●​ Presence of depressive ideation, ideas of worthlessness, guilt, hopelessness and

suicidal ideas.

●​ Presence of magical thinking

MOOD

Depressed mood and congruent affect (accompanied by significant lethargy)

PERCEPTION

Experiences auditory hallucinations: Reports hearing voices of known people (her relatives)

telling her “Burn Burn Burn” (in Sindhi)

COGNITIVE FUNCTIONS

●​ Attention and concentration: Intact

○​ Serial Subtraction: 93, 86, 79, 72

●​ Orientation: Partially intact (oriented to place and person, disoriented to time)

○​ Name: P.M.

○​ Place: RMH

○​ Date: 13th January 2025

○​ Time answered: Around 1pm, Actual time: 10:30am

●​ Memory: Intact
 ○​ Immediate Memory: Intact

○​ Recent Memory:

■​ Food last night- rice, daal

○​ Remote Memory:

■​ Personal childhood event: Going to the mela on her birthday

■​ Recall: Intact

■​ Presented 3 words (blue, banana, cow) and asked to recall after some

time.

●​ General information: Impaired

○​ Name of the Prime Minister: Unable to answer

○​ Major cities in India: Mumbai, Surat, UP, MP and Rajasthan

●​ Intelligence: Adequate

●​ Abstractibility: Intact

○​ Find Similarities:

■​ Table, Chair - Furnitures to sit

■​ Orange, Banana- Fruits

○​ Meaning of Proverb: Answered Correctly

■​ Jaisi karni wasi bharni- tit for tat

■​ Bagal mai chora sheher mai dhindora- could not answer

■​ Kangali mai aata geela - series of misfortunes

●​ Judgement: Partially Impaired

 (a) Personal Judgement: Impaired

(b) Social Judgement: Impaired (If 2 people are fighting what should be done?- will

solve the fight.)

(c) Test Judgement: Intact (What would you do if a stamped, sealed, addressed

envelope is found in the street? - won’t pick it up, will run away, police k lafde mein

koun pade.)

●​ Insight: Impaired
 CLINICAL ASSESSMENTS

Tests Conducted

Rorschach Inkblot Test (ROR)

Millon Clinical Multiaxial Inventory (MCMI 3)

House-Tree-Person (HTP)

Thematic Apperception Test (TAT)- (Suspended due to unwillingness, resistance and

insufficient responding by the patient. Patient further reported not being into story-telling)

RORSCHACH INKBLOT TEST

The Rorschach Inkblot Test is a psychological assessment developed by Hermann Rorschach

that uses inkblots to evaluate a person’s personality presentations, emotional functioning and

thought processes and helps detect presence of any pathology. It gives insight into a person’s

thought organization, self-image, interpersonal relationships, traits and underlying thought

disorders. It is a projective test, making it harder for individuals to manipulate responses by

indulging in random responding or faking good (to show a socially appropriate image) or

faking bad (to overreport or over exaggerate their symptoms.) P.M.’s protocol was valid and

the interpretations can be viewed to be somewhat true about her overall functioning.

It can be understood that P.M. is experiencing some sort of distress or overload, and that her

capacity for control appears to be rather limited, especially in situations that lack structure or

stability. She is highly vulnerable to experiencing distress and becoming disorganised in most

situations, even those which are occurrences of natural everyday living. For instance, she
has reported feeling overwhelmed while managing daily household tasks such as cooking,

which has even led to fights with her husband. Additionally, she mentioned that she often

sleeps excessively as a way to cope, which can also be seen as her becoming disorganized

and withdrawing when daily demands become too much to handle.

Additionally, there is presence of some situational stress and it is leading to some

psychological disruption of moderate intensity and mild emotional confusion. Additionally, it

appears that there is little to no impact of situational stressors on her thought patterns. For

example, her experience of being admitted to the hospital under false pretenses, as well as her

distress about the poor hygiene and discomfort in the ward, caused her visible distress.

However, her persecutory delusions regarding her family’s intentions to harm her and her

auditory hallucinations remained unchanged and unaffected by these specific events,

indicating that her core thought patterns were not significantly influenced by these situational

stressors.

Her coping style appears to be avoidant, which suggests that she might have a tendency to

simplify complicated or ambiguous situations by disregarding or denying some aspects of a

stimulus event. Since she experiences difficulties with control, her coping style of avoidance

(haviing a cautious and conservative orientation) may act as beneficial to her, as it helps in

avoiding emotional stimuli, avoiding complexity and reducing demands that are made on her.

For example, she reported that she often chooses to sleep for long hours during the day

instead of engaging in household responsibilities or addressing conflicts with her husband

and son. This could be seen as a way of avoiding emotionally difficult situations and

minimizing the demands placed on her. Similarly, during her stay in the hospital, she avoided
interacting with other patients and preferred keeping to herself, which is another instance of

her tendency to withdraw from potentially stressful social interactions.

It can also be inferred that P.M. does not have any prominent mediational dysfunction.

However, there is a likelihood that she makes special effort to ensure that her mediation is

appropriate for the situation that she is in, and there is a desire to translate situations

accurately (which is signified by her stating that even in bursts of anger she does not target

her husband or her son.) Additionally, there is also a tendency to make decisions that

disregard social demands or expectations, which could be attributed to being a product of

repeated conflict with the environment, which is in line with P.M.’s case, where

environmental issues are significantly prominent. For example, she has filed multiple

complaints against her husband with the police, despite the social stigma and potential

community backlash that may occur, which can be seen as her prioritizing her immediate

need for safety or justice over conforming to societal norms.

Her scores reflect a tendency of her ideational sets and values being reasonably well-fixed

and are relatively difficult to alter. Furthermore, she has a distinctive tendency to substitute

fantasy in her reality when faced with stressful/unideal situations, such as having hope that

everything with her son will eventually be okay or her description of a “magical pencil” that

she believes can create anything she thinks, showing her tendency to mentally escape into

fantasy as a coping mechanism when real-life circumstances feel unmanageable.

Her scores further indicate that her estimate of her own worth is very negativistic, and that

she regards herself less favourably in comparison to others, which could also reflect feels of

inferiority, inadequacy and worthlessness. Additionally, we can ascertain that the person’s
self-image of the person is based on her life experiences with little to no imaginary influence.

For instance, she has referred to herself as “bholi” (innocent and gullible) multiple times,

which seems to reflect her perception of being naïve and easily taken advantage of.

Additionally, we can ascertain that her self-image is based on her life experiences with little

to no imaginary influence, as seen in her descriptions of feeling “mad” or “useless,” or with

“vo hushyar hai, aage hai aur mein nahi” which seem to stem from her real-life experiences

of neglect, abuse, and being invalidated by her family.

It can also be inferred that P.M. is not as interested in other people and can tend to appear

socially withdrawn. Additionally, since she is avoidant by nature, she might have a tendency

to distance herself from people and avoid contact/confrontation. She might have a tendency

to be less active/restrict herselves in social interactions, indulging in self-isolating behaviour.

In her case, this could be understood to be due to her dissatisfaction with the environment,

interpersonal conflicts and experiences of abuse and isolation from her family. For instance,

during her stay in the hospital, she kept mostly to herself and did not show much interest in

engaging with other patients. She also spoke about spending long hours alone at home sewing

or drawing instead of interacting with her husband or neighbors, further highlighting her

tendency to withdraw and isolate herself as a response to her strained relationships and

difficult living environment.

Summary Of ROR:

The findings on P.M.’s Rorschach protocol suggest that her functioning is marked by distress

and difficulties with control, particularly in unstructured or demanding situations. There are

indications of moderate psychological disruption, avoidant coping tendencies, low self-worth,

social withdrawal, and a reliance on fantasy during stressful times.

HOUSE-TREE-PERSON TEST (HTP)

The House-Tree-Person (HTP) Test is a psychological assessment tool developed by John

Buck that is designed to evaluate an individual’s personality, emotional functioning, and

cognitive processes through their drawings. It is a projective test that involves asking the

individual to draw a house, a tree, and a person, with each drawing serving as a symbolic

representation of different aspects of the self and their environment, and with each drawing

being supplemented by some questions. This provides insight into a person’s self-perception,

interpersonal relationships, coping mechanisms, and potential emotional conflicts. Similar to

other projective tests, it helps in ensuring that the responses are not distorted, such as faking

good (presenting an overly positive image) or faking bad (exaggerating symptoms), making it

a valuable tool for uncovering underlying thoughts, feelings, and potential psychopathology.

P.M.’s manner of drawing can be analyzed to get insight into some personality functioning. In

her drawings, we can see lack of details in some drawings, which could possibly be attributed

to depression. Furthermore, there are also some details which are bizarre or grossly distorted,

which is often believed to be an indication of psychosis. There are mutilations and scars on

her face (as clarified by the patient) which could be chalked up to some form of latent anger.

The drawing of the person provides some insight into her ideal self and her feelings towards

herself. She drew a picture of a 12 year old girl who has injuries (scars and a bandaid) on her

face and has some hurt in her back and can’t stand straight. However she reports that this girl

is happy despite everything, just being by herself or doing her own thing. When asked what

activity the girl is doing, she said “nothing as such” and that the girl “sabse mil-jul k rehti
hai”. This description can be interpreted as her missing her childhood self and wanting to go

back to it. The injuries could imply some form of a hidden trauma. Furthermore, the girl is

facing towards the side, which could show some form of paranoia. The happy self could

indicate contentment and in her case resilience (being happy despite injuries). There are no

visible gender issues. However, the head of the girl is unusually large, which could also be

indicative of psychosis.

The drawing of the tree is believed to be a projection of how they feel about themselves. It is

representative of their actual self- with feelings about self and feelings about self as a

member of society. P.M. drew a mango tree which is around 12 years old. She says that the

tree is alive because it is green, and that the tree gets enough sunlight. The season is currently

monsoon but she says that there are still fruits on the tree. She mentioned that everyone

waters the tree but nobody comes to meet the tree. The tree is on the ground so there is some

touch with reality, but the trunk of the tree has some sketchy lines, which could indicate

feelings of insecurity and being unsure about herself. Furthermore, the drawing is placed

towards the edge of the paper, which could further reflect feelings of inadequacy and

insecurity. The tree branches are spread out, which could be interpreted as a need for

affecttion, but at the same time, the branches are limited and tightly coiled, which could

indicate protecting herself or being reserved. She also said that everyone waters the tree,

indicating that her basic needs are met by those around, but that nobody comes to meet the

tree, which could reflect feelings of loneliness and lack of supportive individuals in the

environment.
The drawing of the house helps gain insight into her current life or even the general

environment growing up. It can further help identify any intra-familial issues. She drew a

picture of a dog house, which is made of cloth. She says nobody visits this house, not even

the owner. Owner’s wife lives in the house, and all she does is eat and sleep. The house is

small with only a hall/living room. The dog house can indicate dissatisfaction with the living

conditions and the material being cloth could indicate lack of support, stability and structure.

Lack of visitors in the house could show lack of familial and social support, suggesting

possible feelings of loneliness. The drawing on the house is “too far” which could signify that

there is difficulty adjusting/finding comfort in the house. The house has a small and closed

door and no windows, which could suggest feeling trapped and disconnected from the world

outside. Overall it signifies a lot of familial/environmental issues.

The insight gathered from this test is in line with P.M.’s case history, wherein she reports ki

“bachpan acha tha, bachpan mein hushyar thi”, which could explain why 12 years is the age

for both her tree and the drawing. Furthermore, dissatisfaction with the home environment is

also revealed through the drawing of the house, as she has also previously referred to her

husband as a “kala kutta.”

MILLON CLINICAL MULTIAXIAL INVENTORY III (MCMI-3)

The Millon Clinical Multiaxial Inventory- III is a psychological test used to assess the

presence and severity of personality and symptom disorders in adults. It is usually used with

the clinical population (people who are undergoing psychodiagnostic evaluation or

psychotherapy) to investigate personality traits, disorders, symptoms and their severity. It is

an objective test containing 175 items with a dichotomous responding pattern (true and false),

and takes approximately 30 minutes to administer.

For the purpose of assessment with P.M., the Hindi version of the MCMI 3 was used. She

was able to understand the items, (however she did require some clarification at times) and

was cooperative and willing to participate in the testing process. Upon analysis of her

responses, validity of the profile was established, indicating that she was true in her manner

of responding. There were little to no inconsistencies in her reporting, and it appears that she

was willing to self disclose her symptoms and problems. Furthermore, no tendency of

overreporting (faking bad) or underreporting (faking good) was observed.

P.M.’s scores indicate that she is somewhat socially detached and might have a tendency to

prefer solitary activities. She might appear to be distant and aloof and may exhibit difficulties

in forming and maintaining relationships. This is in line with her case history, as she reported

interpersonal difficulties with her family members and also reported that she preferred

spending time by herself doing something she likes, like sewing.

It can also be understood that she is severely depressed, to the extent that they are unable to

function in day- to- day activities, which P.M. reports to be true as she is unable to do any
tasks at home or otherwise. She further reports having vegetative signs of clinical depression

(poor appetite and sleep, low energy, loss of interests), and feels hopeless, helpless and

worthless, and also self-critical. She further reports suicidal ideation- which can also be

understood as a tendency to have difficulty in expressing anger and displacing it onto herself

(thoughts of “mein nahi rahungi toh sab theek ho jayega”). She might also be passive and

submissive in some situations and might feel inadequate, which is further in-line with her

case history where she reported feelings of inadequacy, guilt and worthlessness.

She further exhibits self-defeating tendencies and may engage in behaviours that may result

in others taking advantage of her or abusing her, and she may present herself as

“self-sacrificing”. This is also prevalent in her case history with the nature of interpersonal

conflicts that she described in relation to her husband and son. Additionally, she might feel

like she deserves to suffer at the hands of her son, as seen by “maine mere bete ko aise jahil k

saath paala, ab mera beta bhi vaisa hogaya hai”.

There is also a slight elevation in her schizotypal traits suggesting that, at times, her

behaviour might be idiosyncratic or eccentric (i.e. strange or unusual), which is also

highlighted by the presence of magical thinking behaviour, wherein she possesses a set of

pencil that can draw anything one can think of.

P.M.’s scores also reveal a tendency to be emotionally intense, which can be characterized by

feeling heavily dissatisfied and depressed and might eventually translate into self-destructive

behaviour, something that is a prevalent theme in P.M.’s conversations, with dissatisfaction

towards life, marriage and feelings of depression alongside self-destructive behaviour like

setting herself on fire.

It is also seen that her thought patterns have a tendency to be rigid and defensive and hold

delusions of persecution. She might also be mistrusting and may become angry and

belligerent. These anger outbursts can be seen as in line with her case history, when she

would engage in breaking plates in moments of distress.

P.M.’s scores further indicate that she might experience post-traumatic stress disorder, which

can be characterised as unwanted and/or intrusive memories of a disturbing/traumatic event.

Although she denies frequent flashbacks, she does report being distressed and that sometimes

she randomly thinks about her plight in the hospital and gets reminded of the abuse she has

faced from her husband in vivid detail, and that because of those memories she feels

disturbed and “ashant”.

Furthermore, her scores indicate that there is presence of formal thought disorder, as

characterised by presence of hallucinations and delusions, which are in line with what she

reports. She might also have a tendency to be acutely paranoid with her delusions and

irrational thinking. This is in line with her case history as she tends to maintain hostility and

hypervigilance and thinks that everyone wants to get rid of her or want to usurp her property.

Summary of MCMI-III:

P.M.'s scores suggest she is socially withdrawn, prefers solitude, and struggles with

relationships. She appears to be severely depressed, unable to manage daily tasks, and

experiences feelings of hopelessness, worthlessness, and self-criticism. She reports suicidal

thoughts and has difficulty expressing anger, often turning it inward. She shows
self-defeating tendencies, allowing others to take advantage of her, especially in her

relationships with her husband and son. Her thinking can be rigid and defensive, leading to

mistrust, paranoia, and angry outbursts. P.M. also displays schizotypal traits, including

eccentric behavior and magical thinking. Her emotions are intense, often leading to

self-destructive behaviors. She shows signs of PTSD, recalling past abuse in distressing

detail. Additionally, she experiences hallucinations and delusions, believing others want to

harm or exploit her. These symptoms reflect her past trauma, contributing to her emotional

struggles.
 CASE FORMULATION

For the purpose of better understanding this case, we can conceptualize it using the

biopsychosocial model, which is a holistic model to understand health and illness, by

examining the interconnected role of biological, social and psychological factors.

1.​ Biological Factors:

○​ A genetic link can be hypothesized through mom who had episodes of anger

and instances of “mata chadhna”

○​ Thyroid diagnosis and medication (could explain mood fluctuations)

2.​ Psychological Factors: The disturbances in her current functioning can be

understood with some theories like:

○​ Observational learning: Observing mother's anger outbursts and troublesome

behaviour

○​ Hierarchy of needs: Her lower level needs of love and belongingness were

not met at the time of onset of the disorder, which could have led to

psychological disturbances

○​ Cognitive triad: Has persistent themes of helplessness (“ab shaadi k baad kya

hi karungi”), hopelessness (“ab kuch jeevan mein acha nahi hoga, khatam

kardena chahiye khudko”) and worthlessness (“mein aage nahi hu”, “mein

nahi rahungi toh sab khush rahenge”)

○​ Erikson’s stage of Intimacy vs Isolation: Marital conflicts and loss of

familial social support could have caused feelings of isolation, leading to

further distress.
 ○​ Adler’s Inferiority Complex: thinks that she is not as good as her sisters, and

that is why things are good for them but only bad things happen to her

○​ Defence Mechanisms: frequently uses displacement (anger taken out on self

and household objects like plates), possibly uses repression and projection.

3.​ Social Factors:

○​ Unstable environment- initially her mother’s anger outbursts and eventually

husband and son's abuse

○​ Lack of familial and social support

○​ Loss of mother

○​ Lower socio-economic status

○​ Eventual financial dependence on husband

 PROVISIONAL DIAGNOSIS

Based on the case history and clinical assessment conducted on P.M., it can be said that she

meets the criteria for Schizophrenia. As per the DSM-5-TR criteria:

A. Two (or more) of the following, each present for a significant portion of time during a

1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):

1. Delusions.

2. Hallucinations.

3. Disorganized speech (e.g., frequent derailment or incoherence).

4. Grossly disorganized or catatonic behavior.

5. Negative symptoms (i.e., diminished emotional expression or avolition).

P.M. demonstrates positive symptoms, including delusions and hallucinationss. She

experiences persecutory delusions, believing that her relatives and husband are conspiring to

take her property and harm her. Furthermore, she experiences auditory hallucinations, hearing

voices in Sindhi that command her to "burn, burn, burn," leading to a suicide attempt in 2018.

Additionally, her magical thinking, such as believing she owns a magical pencil that can draw

anything without effort, further supports the presence of thought disturbances. These

symptoms are persistent and have significantly impacted her daily life.

B. For a significant portion of the time since the onset of the disturbance, level of

functioning in one or more major areas, such as work, interpersonal relations, or self-care,

is markedly below the level achieved prior to the onset (or when the onset is in childhood or
adolescence, there is failure to achieve expected level of interpersonal, academic, or

occupational functioning).

P.M.’s case shows severe occupational, social, and personal deterioration. Previously

employed at a marketing firm and as a tutor, she is now unemployed and largely dependent

on others. She struggles with self-care, as noted in her poor hygiene and lack of grooming

during the Mental Status Examination (MSE). Socially, her relationships are severely

impaired, as she has become estranged from her siblings, has conflicts with her husband and

son, and believes her relatives and family members are plotting against her. She also exhibits

social withdrawal, preferring isolation and rarely interacting with others.

C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period

must include at least 1 month of symptoms (or less if successfully treated) that meet

Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual

symptoms. During these prodromal or residual periods, the signs of the disturbance may be

manifested by only negative symptoms or by two or more symptoms listed in Criterion A

present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

P.M.’s symptoms have been present for approximately 14 years, beginning around 2011 after

the death of her mother. Over time, her symptoms have worsened, leading to multiple

hospitalizations. Her active-phase symptoms, including delusions, hallucinations, and have

been present for over a month, fulfilling the required duration for schizophrenia diagnosis.

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have

been ruled out because either 1) no major depressive or manic episodes have occurred
concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during

active-phase symptoms, they have been present for a minority of the total duration of the

active and residual periods of the illness.

While P.M. does experience depressive symptoms, including feelings of worthlessness,

hopelessness, guilt, and suicidal ideation, these symptoms do not appear to be the primary

disturbance. Instead, her psychotic symptoms persist independently of mood disturbances, as

evidenced by the chronic presence of delusions and hallucinations even when her mood

symptoms fluctuate.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a

drug of abuse, a medication) or another medical condition.

P.M. denies substance use (e.g., alcohol, drugs, or medications that could induce psychotic

symptoms). Although she has a history of thyroid problems, her psychotic symptoms persist

even when she is on thyroid medication, ruling out a direct medical cause.

F. If there is a history of autism spectrum disorder or a communication disorder of

childhood onset, the additional diagnosis of schizophrenia is made only if prominent

delusions or hallucinations, in addition to the other required symptoms of schizophrenia,

are also present for at least 1 month (or less if successfully treated)

P.M. does not have a history of neurodevelopmental disorders such as autism.

Specify: Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder
are remaining for the majority of the illness course, with subthreshold symptom

periods being very brief relative to the overall course.

Differential Diagnosis:

Schizoaffective Disorder: This disorder includes a combination of schizophrenia symptoms

and mood disorder features. P.M. exhibits depressive symptoms, including low mood,

lethargy,, and suicidal ideation, along with persistent psychotic symptoms. However, for a

diagnosis of schizoaffective disorder, a significant mood episode must be present for the

majority of the illness duration, and psychotic symptoms must also persist for at least two

weeks in the absence of a mood episode. In P.M.’s case, her psychotic symptoms appear to be

more consistent and independent of mood fluctuations. Furthermore, mood fluctuations can

be attributed to her thyroid.

Major Depressive Disorder (MDD) with Psychotic Features: MDD with psychotic

features is characterized by severe depressive episodes accompanied by hallucinations or

delusions. P.M. displays significant depressive symptoms, including hopelessness, fatigue,

and suicidal ideation, in addition to experiencing psychosis. However, in MDD with

psychotic features, hallucinations and delusions typically occur only during depressive

episodes and resolve once the depressive episode is treated. P.M.’s psychotic symptoms have

been ongoing for over 14 years and persist beyond depressive episodes. Furthermore, her

sadness can be viewed as contextual (in relation to her past experiences) or can be attributed

as associated effects of schizophrenia or her thyroid.

Delusional Disorder (Persecutory Type): P.M. has strong persecutory delusions, believing

her relatives and husband want to harm her. In delusional disorder, the delusions are

well-structured and persistent but do not significantly impair overall functioning beyond the

delusional belief. Additionally, hallucinations are not a prominent feature. However, P.M.

exhibits auditory hallucinations, which does not meet the criteria of delusional disorder.
 TREATMENT PLAN

Session 1: Establishing rapport, creating a safe space and symptom understanding

Objectives:

●​ Building a trusting therapeutic alliance.

●​ Validating and normalising her distress while reducing feelings of isolation.

●​ Assessing her stressors, triggers, and current coping mechanisms.

●​ Providing psychoeducation about emotional distress and coping styles.

Steps & Activities:

●​ Beginning with a calm, empathetic approach.

●​ Acknowledging her struggles without focusing heavily on pathology

●​ Exploring her day-to-day stressors (e.g., conflicts at home, son’s behavior, financial

strain) and discussing situations where she feels most overwhelmed or disorganized.

●​ Clarifying the nature of her avoidance (e.g., when she chooses to withdraw, what

situations she avoids).

●​ Normalizing her avoidance as a natural but sometimes unhelpful coping style.

●​ Introducing the idea of “small steps” toward facing stressors and importance of

adhering to medications

Outcomes:

●​ P.M. begins to feel understood and supported.

●​ Increased awareness of her triggers and coping patterns.

●​ Reduced self-blame as her avoidance is reframed as a coping attempt.

●​ Becoming ready to do skill development in the next session.

Session 2: Building coping strategies and emotional regulation

Objectives:

●​ Introducing emotional regulation and distress tolerance skills.

●​ Reducing avoidance by promoting small, manageable actions.

Steps & Activities:

●​ Teaching simple grounding techniques like backward counting or staying in the

moment (5-4-3-2-1 exercise: Identify 5 things you see, 4 things you touch, 3 things

you hear, 2 things you smell, 1 thing you taste) that she can use in situations she is

overwhelmed

●​ Helping P.M. identify her emotions in overwhelming moments and reinforcing that

emotions, even the intense ones, are valid and manageable.

●​ Identifying one situation she tends to avoid (e.g., prolonged conversations with

family, handling son’s behavior without withdrawing), and collaboratively we can set

small, specific goals to incorporate in that situation (e.g., “Stay in the room for 5 extra

minutes during a difficult conversation before leaving”).

●​ Introducing questions to challenge emotional assumptions (e.g. “what evidence

supports this?”) and practicing it in a recent situation (e.g., a conflict with her

husband).

Outcomes:

●​ P.M. shifts her perception of distress by recognizing that emotions, though intense, are

not always an indication of failure and gains tools to reduce emotional overwhelm

●​ She starts experimenting with reducing avoidance in small, controlled ways.

Session 3: Strengthening her self-worth and social connections

Objectives:

●​ Addressing her negative self-worth and feelings of inferiority.

●​ Encouraging re-engagement with existing supportive social relationships or building

new helpful relationships

●​ Developing a plan for ongoing emotional and practical support.

Steps & Activities:

●​ Reflecting on strengths observed in the past sessions (e.g., her care for her son, her

resilience in managing household stress).

●​ Help her understand the importance of social involvement by explaining that social

withdrawal reinforces low self-worth and negative thoughts.

●​ Practice this in the session by identifying a low-stress social interaction (e.g., calling a

relative, greeting a neighbor) and help her take small steps to rebuild connection.

●​ Discuss options for extending her support network (e.g., community groups, further

therapy, or engaging with social workers if abuse continues).

●​ Help her to identify early warning signs of emotional overwhelm (e.g., constant

fatigue, desire to isolate).

●​ Developing a go-to plan for difficult days (e.g., grounding, contacting a trusted

person, brief relaxation activity) and encourage her to create her own grounding kit by

listing out grounding and emotion-regulation techniques she finds most helpful and

enjoys (e.g. brief walks, creative work like sewing etc).

●​ Acknowledging her progress and capacity for small but impactful changes.
Outcomes:

●​ P.M. starts viewing herself as capable and resilient.

●​ She has increased comfort in initiating social contacts.

●​ She is equipped with a practical plan for managing future distress.

●​ She has a greater sense of direction for both emotional and situational challenges.
 CASE 4

CASE HISTORY

Name: M.I.

Age: 35

Date of Birth: 23/10/1989

Date of Assessment: 15/01/2025

Sex: Female

Education: BA in History

Occupation: Currently unemployed

Informant: Mother

COMPLAINTS AND THEIR DURATION

MI reports distress from symptoms of severe depression. She also reports impairments in

social and occupational functioning. She is unable to concentrate on her work. She also

reports being scared of men and marriage. She expresses frustration about her fathers death

causing legal troubles for her. She also reports feelings of anxiety and intrusive memories of

her assault. She and her mother also report her decreased appetite and sleep. She reports

experiencing these symptoms for almost 15 years which have increased in intensity after her

brother’s death 2 years ago and have further worsened since her father committed suicide in

November 2024.
HISTORY OF PRESENT ILLNESS

MI has been coming to RHM’s OPD for the past 2 months with her mother. She reported

symptoms of depression and trauma. She reports being sexually and physically assaulted by

her father for around 7 years from when she was 14 years old until her graduation. She

reported that initially she did not understand the meaning of her father’s behaviour towards

her and for the first few months, it did not go beyond touching inappropriately and that she

felt weird but did not understand anything. However, she said that soon her father started

having penetrative intercourse with her and this is when she did understand about his

behaviour being wrong. She further reports that her father threatened her saying “tujhe ghar k

bahar fek dunga”, “tujhe bohot maarunga” etc, and that because of this she was too scared to

talk about it to anyone or ask for help. However after graduation she talked to her mother

about the 7 year long assault. Her mother planned a family intervention where the father

apologized, and then she reportedly stopped any further direct and private interactions

between Maninsha and her father so he couldn’t assault her and would fight her husband for

her daughter which did stop the sexual assault. However, her mother continued to stay with

her husband until he left them for another woman. Since the assault MI reports experiencing

repeated memories and flashbacks of her assault in her dreams or whenever is about to sleep.

She also reports being scared and paranoid around men - her male colleagues, (to the point of

actively avoiding them) and getting married and also reports flinching whenever a man gets

too close to her. She also reports pain in her stomach and neck whenever she remembers the

memories of her assault. She reports low self-esteem since then and has negative thoughts

about herself and her future (“My life is ruined and now I can’t do anything with my life

because of what my father did to me’’). Similarly, she reports feelings of hopelessness,

worthlessness and disinterest in doing anything which includes her education (where she
failed her exams and failed her 10th Board exams) and later on work. She reports trouble

falling asleep (feeling scared to do so”) and also decreased appetite along with inability to

concentrate. She reports that all her symptoms have also greatly impaired her work, where

she was previously fired due to issues with her attention and concentration and overall

paranoia around male colleagues. MI reports that all these symptoms have increased after her

brother’s death 2 years ago (2023) but that she was able to manage her anxiety initially.

However, she reported that her symptoms and her anxiety kept worsening- especially her

flashbacks - after her father died by commiting suicide in front of their house when they were

sleeping which caused the police to investigate her and her mother which led to long trips and

waiting at the police station and a lot of paperwork. She reports seeking help throughout the

years but it has been inadequate to her (one counselor she was talking to was focusing more

on her fathers intentions and “justifying” his behavior and sidelined her concerns). She

further reports that her symptoms have become absolutely unmanageable now, which is why

she is seeking psychiatric help.

Onset: Reported to be around 15 years ago, but has worsened over the years due to life

circumstances and inadequate help

Course of the Illness: Gradual

Predisposing Factors: History of depression (mother and brother) and suicide (father and

brother) in the family

Precipitating Factors: Being sexually molested in her sleep by her father at the age 14 up

until her graduation

Perpetuating Factors: Her brother’s death by suicide, father’s death by suicide in front of

their door, police being behind them for her father’s death, inadequate treatment by the

hospital, inadequate help by her counselor and severe community backlash

Protective Factors: Relationship with her mother

Associated Disturbances:

●​ Inattention and unable to concentrate,

●​ decreased sleep,

●​ decreased appetite,

●​ avoiding interactions especially with the opposite gender

Treatment: MI is currently on medication prescribed at the OPD at RMH. She is on

antidepressant tablets Fluvoxamine 10mg and Chlomipramine 10mg. She is also prescribed

mood stabilizing tablet Carbamezapine 15mg. For her anxiety, she has been prescribed Novo

Lorazepam 15mg and Diazepam 5mg.

PAST HISTORY

None reported. Absence of diseases, accidents, hospitalizations. Reports one isolated incident

of breaking her hand while playing.

FAMILY HISTORY

MI was born to Mr and Mrs on October 23, 1989. 3 years after MI’s birth, the couple also

had a son named Mayur. MI reports that her mother is a shop owner and that her father was a

hotel manager, so from a young age she spent a lot of time with her brother and that they

were very close. She said that she was also very close to her mother, because she was always

there for them and spent time with them despite being busy. She further stated that some of

her best memories are of the three of them spending time together, or being with her brother.

She further reported that her father wasn't around much when she was a child, as he usually

had night shifts or on most days double shifts, but he gave them everything they wanted. He

was very strict with MI and Mayur, so they never developed much of a close bond with him.

MI started to face familial troubles when she was 14 years old. She reports that it was around

this time she hit puberty and her dad switched to day shifts, and that he used to come into her

room late at night and touch her. She said for sometime initially it never went beyond

touching and despite her feeling weird, she thought that he wasn’t doing anything wrong and

that she was being paranoid. However, eventually he started to have penetrative intercourse

with her, and she realized that his behaviour was wrong, but he threatened her to not say

anything to anyone or he would hit her and throw her out of the house. The abuse persisted

till her graduation (for a little more than 7 years) until she broke down in front of her mother

and confessed about it when her family was speaking about the possibility of her getting

married. Her mother organized a family intervention and confronted the father, who broke

down and apologized, and swore on his children’s lives that he would never repeat it again.

MI reported that post this incident her mother prevented any direct interactions between her

and her father. She also reports that her brother distanced himself from his father and stopped

speaking to him. She said that he used to patrol outside her room at night as he wanted to
protect her, and that his presence really helped her back then. Despite this incident, her

mother never divorced her father, and that her mother had a good relationship with her father

and always took care of him and took his side in any arguments (especially between the kids

and him). She reports feeling really betrayed by her mom’s behaviour and that she could not

understand how or why she would take his side, which soured her relationship with her

mother for some time. Her mother’s relationship with her father only began deteriorating

when a police case for harassment was filed against her father. It was discovered that he used

to coerce women at his work to have sex with him and he used to take inappropriate photos of

them, and one of the girls filed a case because of which her entire family received lots of

judgement from the community. When her mother confronted him, he also revealed that he

had been having an affair with a woman (who the family knew well) and that he wants to be

with her and have kids with her to start his life afresh, and that he got his vasectomy reversed

for this woman and left the house. This blow hit her mother really hard and she went into a

state of depression, doing nothing but cry and sleep all day. Additionally the family received

a lot of hate and criticism from those around and they were unable to cope with it. MI reveals

that her only source of support was her brother, but had a conflict with him when he started

consuming alcohol and drugs. It was around this time that MI felt a lot of sympathy for her

mother and began supporting her, and their relationship improved. She reports that her

brother also swore to stop consuming substances and that he was sober for 8 months before

he started getting blackmailed by his friends. Unable to cope with it, he committed suicide in

2023. MI reveals that she and her mother both became distraught and incosolable at this time,

but that she had to be strong to take care of her mother. She notes that the father did not come

for the son’s funeral and was not remorseful of his death. MI reports that losing her brother

caused her symptoms to worsen and she was fired from her job. She reports that they relied

on her mother’s shop for their income and the two of them were doing fine until late October
in 2024, when the father came to their place drunk and revealed that his affair partner had left

him because she wanted to be with her husband and kids and stopped talking to him. He kept

harassing them until eventually he told them that “tum logo ne meri zindagi kharab kar di

hai” and committed suicide on their doorstep, which led to them getting caught up in “legal

drama” and “police station ka rasta napna”. This situation added to their distress. Currently

both MI and her mother are seeking treatment at RMH.

PERSONAL HISTORY

Birth and early development: Reported to be normal (by mother).

Behaviour during childhood: She reports being an average child, who was bubbly and

playful.

Physical illnesses during childhood: Denies substantial physical illnesses, and did not get

sick often, however once broke her left hand while playing in the park.

School: Failed 10th. Completed BA in History from Somaiya College.

Occupation: She is currently unemployed. She used to work previously but was fired due to

issues with her attention and concentration and overall paranoia around male colleagues.

Menstrual history: Reports normal and regular.

Sexual history: She has been sexually assaulted before, by her father. Other than that, there

is no instance of sexual intercourse. She further reports being disgusted by the prospect.

Marital history: Has never been married before and expresses a desire to not get married

either “kyuki vo mere baap jaisa nikla toh?”

Use and abuse of alcohol, tobacco and drugs: Denies consumption of any substances
NEGATIVE HISTORY

Marital history, TBI, substance use, past physical and psychiatric illnesses

PREMORBID PERSONALITY

Attitudes to others in social, family and sexual relationships: She reports being friendly

and making friends easily, and she used to look forward to enjoying her time with her brother.

Attitudes to self: She viewed herself as kind and happy.

Moral and religious attitudes and standards: She is religious, a devotee of lord Ganesh,

and prays regularly.

Mood: Reports normal,

Leisure activities and interests: Liked listening to music and going on walks.

Fantasy life: Wants to live with her brother and mother “inn jhamelo se dur”

Reaction pattern to stress: Avoidance

Habits: Reported normal sleep, appetite and excretory functions.

A DAY IN THEIR LIFE

She reports spending her day doing household chores and then helping her mother at the

store, and going for a walk in the evening and reading self-help books at night

COPING STYLES

Avoidance and suppressing her thoughts

 MENTAL STATUS EXAMINATION (MSE)

GENERAL BEHAVIOUR

MI appeared to be well groomed and hygienic. She was conscious and held her attention.

She maintained eye contact throughout the session. Adequate rapport was established and she

was cooperative during the session. It was observed that she was comfortable with her mother

also being present in the later part of the session.

PSYCHOMOTOR ACTIVITY

Normal

TALK

Amount of speech: Normal

Tone: Normal

Tempo: Normal​

Reaction Time: Normal

Speech coherent, relevant and responds to questions.

THOUGHT

●​ Absence of flight of ideas, retardation of thinking, circumstantiality, preservation,

thought blocking.

●​ Absence of formal thought disorder

●​ Absence of obsessions and compulsions, thought alienation.

●​ Absence of delusions.
CONTENT

●​ Presence of worries and preoccupations (about her safety and future), and somatic

symptoms (pain in stomach and neck).

●​ Presence of depressive ideation, ideas of worthlessness, hopelessness and suicidal

ideas.

●​ Absence of delusions.

MOOD

Depressed mood and congruent affect

PERCEPTION

Absence of hallucinations.

COGNITIVE FUNCTIONS

●​ Attention and concentration: Intact

○​ Serial Subtraction: 93, 86, 79, 72

●​ Orientation: Intact

○​ Name: MI

○​ Place: RMH

○​ Date: 13th January 2025

○​ Time answered: Around 9:30 am, Actual time: 9:45am

●​ Memory: Intact

○​ Immediate Memory: Intact

 ○​ Recent Memory:

■​ Food last night- chapati and bhaji

○​ Remote Memory:

■​ Personal childhood event: Going to the mela on her birthday

■​ Recall: Intact

■​ Presented 3 words (blue, banana, cow) and asked to recall after some

time.

●​ General information: Adequate

○​ Name of the Prime Minister: Modi

○​ Major cities in India: Mumbai, Delhi, Jaipur, Ahmedabad, Banglore

●​ Intelligence: Adequate

●​ Abstractibility: Intact

○​ Find Similarities:

■​ Table, Chair - Furnitures to sit

■​ Orange, Banana- Fruits

○​ Meaning of Proverb: Answered Correctly

■​ 1) Jaisi karni wasi bharni- tit for tat

■​ 2) Bagal mai chora sheher mai dhindora-

■​ 3) Kangali mai aata geela -

●​ Judgement: Intact

(a) Personal Judgement: Intact

 (b) Social Judgement: Intact (If 2 people are fighting what should be done?- will solve

the fight.)

(c) Test Judgement: Intact (What would you do if a stamped, sealed, addressed

envelope is found in the street? - give it to the post office)

●​ Insight: Intact
 CLINICAL ASSESSMENTS

Tests Conducted

House-Tree-Person (HTP)

Beck’s Depression Inventory (BDI)

Beck’s Anxiety Inventory (BAI)

PTSD Checklist for DSM 5 (PCL-5)

Millon Clinical Multiaxial Inventory III (MCMI 3) (was not conducted as client was

intimidated by the number of items)

Rorschach Inkblot Test (ROR) (not conducted due to time constraints at OPD)

HOUSE-TREE-PERSON TEST (HTP)

The House-Tree-Person (HTP) Test is a psychological assessment tool developed by John

Buck that is designed to evaluate an individual’s personality, emotional functioning, and

cognitive processes through their drawings. It is a projective test that involves asking the

individual to draw a house, a tree, and a person, with each drawing serving as a symbolic

representation of different aspects of the self and their environment, and with each drawing

being supplemented by some questions. This provides insight into a person’s self-perception,

interpersonal relationships, coping mechanisms, and potential emotional conflicts. Similar to

other projective tests, it helps in ensuring that the responses are not distorted, such as faking

good (presenting an overly positive image) or faking bad (exaggerating symptoms), making it

a valuable tool for uncovering underlying thoughts, feelings, and potential psychopathology.
MI’s manner of drawing can be analyzed to get insight into some personality functioning. Her

pressure to the pen was very light, which could signify some hesitation, timidness and/or

insecurity. Her placement of her drawings on the page was high, which could indicate some

level of fantasy wishing of solving problems. Her drawings are very small, further signifying

the presence of anxiety issues with confidence and beliefs of self-worth and self-doubt are

present. Additionally, there is a lack of details in her drawings, which could be attributed to

depression.

The drawing of the person is believed to be a reflection of the ideal self. It can give insight

into her views and beliefs about herself. She drew a stick figure, which ideally should

indicate issues with cooperation, but MI mentioned that she is bad at drawing human figures

and does not feel confident about it and hence drew a stick figure. However, it was noticided

that there were some mutilations in her drawing (body was missing, only hands and legs.)

She mentioned that “body k saath bohot se cheeze hui hai toh body nihi hai ab” which could

indicte that there were unpleasant experiences which led to some latent anger. She mentioned

that the image is of her and that the person is 35 years old. She expressed that the person is

scared, unhappy and lonely. She said that the person wants to get better soon, wants to travel

and live normally.

The drawing of the tree is believed to be a projection of the actual self. It helps understand

how the person views themselves and how they see themselves as a member of society. She

drew a coconut tree that is 15 years old. She says that the tree is alive and was watered by one

small boy regularly, but now the boy does not come and nobody takes care of the tree

anymore, which could indicate loss of a stable relationship and subsequent feelings of

loneliness. She says that it is currently a long winter and that’s why the fruits are not growing,
which might indicate that there is some level of functioning that is impaired. There is some

scarring on the tree from where the people hit it, which could reflect some experience with

trauma and abuse (as is true in her case.) The branches can be seen to be spread out, which

could show some need for affection. The tree is on the ground, which means there touch with

reality

The drawing of the house helps reveal perception about the environment and interpersonal

relationships. She drew a small house that she owns and that is made of cement. The house

appears to be placed far, which could indicate lack of comfort and difficulty adjusting in the

house. Furthermore, the house only has 1 small door and no windows which indicates that

there is a tendency to distance herself from people and isolate, and is not willing to let others

get close. She said that she lives alone in the house and only her mother visits sometimes. It

indicates lack of stable and supportive relationships and/or a lack of willingness to form new

relationships. Therefore, it can be ascertained that there are some environmental/interpersonal

issues present.

The findings from her HTP are in line with MI’s case history and provides insight into

fixations and distressing areas of her life.

BECK’S DEPRESSION INVENTORY (BDI)

The Beck’s Depression Inventory is a 21-item self-report inventory used to screen out

presence and intensity of depressive symptoms at the time of assessment. The assessment was

carried out in English and she was able to understand the questions. Her score on the BDI

was 43, which is indicative of extreme depression.

MI reported severe symptoms of extreme sadness which she cannot stand, feeling guilt most

of the time, feelings of being punished, unable to cry even when she wants to, feeling irritated

all the time, losing all interest in other people, inability to do any work at all, waking up

several hours earlier than she used to and unable to get back to sleep and completely losing

interest in sexual activities.

Moderate disturbances were reported through symptoms of looking back at past failures,

inability to get real satisfaction out of anything, difficulty in making decisions than before,

getting tired from doing almost anything, appetite being much worse than before and

worrying about physical problems so much that it's hard to think of much else.

MI showed mild disturbance in the domains of being disappointed in herself, being critical of

herself for her weaknesses or mistakes, and having thoughts of killing herself, but with no

intentions to carry them out. She denied being discouraged about her future, doesn't feel that

she looks any worse than before and hasn’t lost much weight lately.

Overall, MI’s result suggests that her levels of depression are extreme and her case history

also supports her results.

BECK’S ANXIETY INVENTORY (BAI)

The Beck’s Anxiety Inventory is a 21-item self-report inventory used to screen out presence

and intensity of anxious symptoms at the time of assessment. The assessment was carried out

in English and she was able to understand the questions.

Her score on the BAI is 39, which indicates high and potentially concerning levels of anxiety.

MI reported being highly disturbed by severe symptoms of being unable to relax, fearing the

worst, feeling of dizziness or lightheadedness, feeling her heart pounding/racing, feeling

terrified or afraid, fear of losing control, feeling scared, experiencing indigestion and feeling

faint/lightheaded.

She also reported moderate disturbances of feeling numbness or tingling, unsteady, feeling

nervous and trembling of hands.

She reported mild disturbances in experience feeling hot, shaky/unsteady, difficulty in

breathing and has a fear of dying all of which doesn’t bother her much.

She denies feeling wobbliness in legs, feeling of choking, face flushing and does not break

into hot/cold sweats.

Overall, MI’s result suggests that her levels of anxiety are concerning and her case history

also supports her results.

PTSD CHECKLIST (PCL-5)

The PCL-5 is a symptom checklist, used to assess whether a person’s concerns meet the

symptom criteria of PTSD as per the DSM-5. It also has a version dedicated specifically for

individuals in the military, and allows a person to indicate the severity of each of the PTSD

symptoms across a five point likert scale which further.

She reported extreme intensity of the following symptoms:

●​ Feeling very upset when something reminded you of the stressful experience

●​ Having strong physical reactions when something reminded you of the stressful

experience (for example, heart pounding, trouble breathing, sweating)

●​ Avoiding memories, thoughts, or feelings related to the stressful experience

●​ Having strong negative feelings such as fear, horror, anger, guilt, or shame

●​ Loss of interest in activities that you used to enjoy

●​ Trouble experiencing positive feelings (for example, being unable to feel happiness or

have loving feelings for people close to you)

●​ Having difficulty concentrating

●​ Trouble falling or staying asleep

She reported strong intensity of these symptoms:

●​ Repeated, disturbing, and unwanted memories of the stressful experience

●​ Suddenly feeling or acting as if the stressful experience were actually happening again

(as if you were actually back there reliving it)

 ●​ Having strong negative beliefs about yourself, other people, or the world (for

example, having thoughts such as: I am bad, there is something seriously wrong with

me, no one can be trusted, the world is completely dangerous)

●​ Blaming yourself or someone else for the stressful experience or what happened after

it

●​ Feeling distant or cut off from other people

●​ Being “superalert” or watchful or on guard

●​ Feeling jumpy or easily startled

She indicated moderate presence of these symptoms:

●​ Repeated, disturbing dreams of the stressful experience

She reported little to no presence of these symptoms:

●​ Irritable behavior, angry outbursts, or acting aggressively

●​ Trouble remembering important parts of the stressful experience

●​ Taking too many risks or doing things that could cause you harm?
 CASE FORMULATION

For the purpose of better understanding this case, we can conceptualize it using the

biopsychosocial model, which is a holistic model to understand health and illness, by

examining the interconnected role of biological, social and psychological factors.

1.​ Biological Factors: There is a history of suicidality, depression and substance abuse

in her family, which might indicate a genetic vulnerability to psychological distress.

2.​ Psychological Factors: The disturbances in her current functioning can be

understood with some theories like:

○​ Psychodynamic theories: The psychodynamic approach, especially Freud’s

theories, suggests that early childhood experiences shape unconscious

conflicts and defense mechanisms that influence behavior. MI’s trauma,

particularly the abuse she faced and the betrayal by her mother of defending

her dad, along with the legal struggles she is currently facing, may have

contributed to deeply rooted psychological conflicts.

○​ Defence Mechanisms: Her reactions to men, her coping style and not

confronting her mother could indicate heavy usage of repression and

avoidance.

○​ Hierarchy of Needs: She might currently be unable to fulfill her ultimate

human potential due to her lower level needs of safety and security, and love

and belongingness not being met, which may cause psychological distress and

disruption.
 ○​ Erikson’s psychosocial stages: She was exposed to trauma and abuse during

her stage of Identity was Role confusion, which might have impacted her

overall identity formation and views of self competence. Furthermore, this

might have also contributed to hindering her functioning in the stage of

Intimacy vs Isolation, as she was “betrayed’ by close individuals and she lost

her only “close” support, her brother, making it difficult for her to form

intimate relationships and bonds. She is currently in the stage of Generativity

vs Stagnation, and she reports being unable to work, which is further adding to

her distress as she does not feel “normal”

○​ Cognitive triad: Presence of persistent themes of worthlessness, guilt and

hopelessness.

○​ Behavioural theories: MI’s symptoms and coping mechanisms can be

understood through classical and operant conditioning. In classical

conditioning, a neutral stimulus becomes associated with a traumatic event,

causing distress when encountered later. For MI, reminders of her abuse-such

as men in positions of power or legal proceedings-have become conditioned

stimuli that trigger panic, emotional distress, and physical symptoms like

stomach pain and tension.

3.​ Social Factors:

○​ Exposure to physical and sexual abuse

○​ Loss of family members (suicides) and legal struggles have left her isolated.

○​ Community stigma and backlash around father’s identity

○​ Job-related distress and financial instability add to her anxiety, reinforcing

feelings of insecurity and helplessness.

PROVISIONAL DIAGNOSIS

Based on the case history and clinical assessment conducted on MI, it can be said that she

meets the criteria for Post-Traumatic Stress Disorder. As per the DSM-5-TR criteria:

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or

more) of the following ways:

1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as it occurred to others.

3. Learning that the traumatic event(s) occurred to a close family member or close friend.

In cases of actual or threatened death of a family member or friend, the event(s) must have

been violent or accidental.

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)

(e.g., first responders collecting human remains; police officers repeatedly exposed to

details of child abuse).

MI experienced prolonged sexual and physical assault by her father for seven years, which

involved molestation, threats, and forced penetrative intercourse. Sexual violence is explicitly

listed as a qualifying traumatic event in DSM-5-TR. Additionally, she has witnessed her

father’s suicide in front of her house, another traumatic event involving actual death.

B. Presence of one (or more) of the following intrusion symptoms associated with the

traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

2. Recurrent distressing dreams in which the content and/or affect of the dream are related

to the traumatic event(s).

3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the

traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the

most extreme expression being a complete loss of awareness of present surroundings.)

4. Intense or prolonged psychological distress at exposure to internal or external cues that

symbolize or resemble an aspect of the traumatic event(s).

5. Marked physiological reactions to internal or external cues that symbolize or resemble

an aspect of the traumatic event(s).

MI reports the presence of intrusion symptoms associated with her traumatic event which

began after her assault. They include recurrent, involuntary, and distressing memories of the

abuse. She experiences intrusive memories and flashbacks related to the sexual assault. There

is a presence of distressing dreams related to trauma and she also reports having flashbacks

before sleeping. There is also the presence of intense psychological distress when reminded

of trauma where she experiences anxiety, intrusive memories, and physical pain (stomach and

neck) when remembering the assault.

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after

the traumatic event(s) occurred, as evidenced by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or

closely associated with the traumatic event(s).

2. Avoidance of or efforts to avoid external reminders (people, places, conversations,

activities, objects, situations) that arouse distressing memories, thoughts, or feelings about

or closely associated with the traumatic event(s).

MI reports persistent avoidance of stimuli associated with her assault which began after her

assault. She tends to avoid external reminders of the event where she avoids men and

marriage, flinching when men come near her, and avoidance of male colleagues.

D. Negative alterations in cognitions and mood associated with the traumatic event(s),

beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or

more) of the following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to

dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the

world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,”

“My whole nervous system is permanently ruined”).

3. Persistent, distorted cognitions about the cause or consequences of the traumatic

event(s) that lead the individual to blame himself/herself or others.

4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

5. Markedly diminished interest or participation in significant activities.

6. Feelings of detachment or estrangement from others.

7. Persistent inability to experience positive emotions (e.g., inability to experience

happiness, satisfaction, or loving feelings).

MI reports negative alterations in cognitions and mood associated with her assault which

began and worsened after her assault. MI reports persistent negative thoughts and beliefs

about herself and her future, as seen in her statements like “My life is ruined and now I can’t

do anything with my life because of what my father did to me.” She also experiences
persistent negative emotional states such as worthlessness, hopelessness, and guilt. Her

self-esteem has been severely affected since the trauma, and she has developed an intense

fear and distrust of men, avoiding them altogether. Additionally, she has lost interest in many

activities, including her education and work, as shown by her failing exams and eventually

being fired from her job. Her emotional detachment and feelings of betrayal towards her

mother after she stayed with her abusive husband further highlight the persistent impact of

the trauma on her cognition and mood.

E. Marked alterations in arousal and reactivity associated with the traumatic event(s),

beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or

more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed

as verbal or physical aggression toward people or objects.

2. Reckless or self-destructive behavior.

3. Hypervigilance.

4. Exaggerated startle response.

5. Problems with concentration.

6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

MI reports marked alterations in arousal and reactivity associated with her assault which

began and worsened after her assault. MI demonstrates several signs of hyperarousal. She

experiences heightened anxiety, especially around men, and actively avoids them. She has an

exaggerated startle response, as shown by her flinching whenever a man gets too close. Her

sleep disturbances, such as trouble falling asleep due to fear and recurring nightmares of her

assault, also indicate increased arousal. She struggles with concentration and attention,
leading to impairment in her work and daily functioning. The stress and paranoia caused by

her interactions with the police further exacerbated her symptoms, making her feel constantly

on edge and worsening her anxiety.

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

MI’s symptoms have persisted for nearly 15 years, worsening over time due to additional

traumatic experiences, such as her brother’s and father’s suicides.

G. The disturbance causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

MI’s symptoms have caused severe impairment in her social and occupational functioning.

She has been unable to maintain employment due to difficulties with concentration,

avoidance of male colleagues, and overall paranoia. Her relationships, particularly with her

mother, have also suffered, as she struggled with feelings of betrayal and resentment.

H. The disturbance is not attributable to the physiological effects of a substance (e.g.,

medication, alcohol) or another medical condition.

MI’s symptoms cannot be attributed to substance use or a medical condition. She has no

reported history of alcohol, tobacco, or drug use, and there is no evidence of a physiological

cause for her psychological distress.

Differential Diagnosis:
Major Depressive Disorder (MDD): MI reports multiple symptoms consistent with Major

Depressive Disorder, including persistent feelings of sadness, hopelessness, and

worthlessness, disturbed sleep and appetite, along with difficulty concentrating, which have

affected her ability to work and function in daily life. Her suicidal ideation and low

self-esteem further indicate a depressive disorder. However, while MDD explains her

mood-related symptoms, it does not fully account for her trauma-related distress, flashbacks,

avoidance behaviors, and hyperarousal, which are more characteristic of PTSD.

Generalized Anxiety Disorder (GAD): MI experiences significant anxiety and excessive

worry, particularly related to her safety and future. She reports fear of men, paranoia around

male colleagues, and avoidance of social interactions and her physical symptoms such as

stomach and neck pain related to trauma memories resemble somatic symptoms often seen in

GAD. However, GAD does not typically involve intrusive trauma-related flashbacks,

nightmares, or dissociative symptoms, which are prominent in MI’s case.

Psychotic Disorders: MI reports flashbacks which are to be be distinguished from illusions,

hallucinations, and other perceptual disturbances that may occur in schizophrenia, brief

psychotic disorder, and other psychotic disorders; depressive and bipolar disorders with

psychotic features; delirium; substance/medication-induced disorders; and psychotic

disorders due to another medical condition. PTSD flashbacks in MI’s case are directly related

to the traumatic experience of her assault and are occurring in the absence of other psychotic

or substance-induced features.
 TREATMENT PLAN

Session 1: Establishing Safety and Emotional Regulation

Objectives:

1.​ Establishing a therapeutic alliance and creating a sense of emotional and physical

safety.

2.​ Identifying and acknowledging emotional distress and triggers related to her past

trauma.

3.​ Introducing and practising grounding and relaxation techniques to manage her distress

and anxiety.

Steps and activities:

●​ Explaining the impact of trauma on mental health, focusing on depression, PTSD,

anxiety, and how past experiences shape emotional and cognitive patterns.

●​ Helping MI recognize the emotional triggers related to past traumas and track

physiological responses to them. Additionally, teaching and practicing techniques

such as deep breathing exercises, progressive muscle relaxation, guided imagery, and

the 5-4-3-2-1 technique, to help her manage these responses.

●​ Assigning MI to maintain a journal documenting distressing emotions, thoughts, and

situations that trigger her anxiety and trauma responses

●​ Guiding her in identifying and visualizing a mental safe space where she feels secure

and at ease.

●​ Explain the importance and purpose of her medications, and enforce her to stick to a

regular medicine schedule.

Outcomes:

●​ MI establishes trust in the therapeutic process and feels a greater sense of emotional

safety.

●​ She gains insight into how trauma affects her emotional and physiological responses

and begins to practice at least one grounding technique effectively.

●​ Her ability to manage acute distress improves slightly, reducing overall emotional

dysregulation.

Session 2: Addressing Cognitive Distortions and Enhancing Coping Skills

Objectives:

●​ Explore past traumatic memories in a structured and emotionally safe manner.

●​ Identifying, acknowledging, and challenging negative self-beliefs.

●​ Introducing cognitive restructuring techniques to modify maladaptive thought

patterns.

●​ Developing healthier coping mechanisms for distressing thoughts and emotions.

●​ Encouraging re-engagement in small, meaningful daily activities to improve mood

and self-worth.

Steps and activities:

●​ Allowing her to discuss in detail her trauma and past experiences and expressing her

thoughts on it in an empathetic environment

●​ Working on identifying automatic negative thoughts that have arose as a result of the

trauma (e.g., "My life is ruined") and replacing them with realistic, compassionate

self-statements.
 ●​ Encouraging MI to engage in small pleasurable activities she previously enjoyed (e.g.,

listening to music, taking nature walks, creative activities).

●​ Guiding her through an imagery exercise where she envisions a place where she feels

safe, calm, and at peace.

●​ Practicing assertive communication skills, helping her express boundaries and needs

effectively, especially regarding interactions with men and authority figures.

●​ Introducing exercises focusing on self-kindness, mindfulness, and reducing

self-judgment.

Outcomes:

●​ MI feels better about venting out her story through her lens and gains some

relief/llight-heartedness

●​ She becomes more aware of how her thoughts influence her emotions and behaviors.

●​ She starts challenging negative thoughts and replacing them with more adaptive,

empowering ones.

●​ She is able to engage in at least one pleasurable activity daily, enhancing emotional

well-being.

●​ She reports a small but noticeable improvement in her mood, self-esteem, and ability

to cope with distress.

Session 3: Processing Trauma and Developing Long-Term Coping Strategies

Objectives:

●​ Developing long-term coping strategies for intrusive thoughts, flashbacks, and anxiety

and empowering MI with tools for emotional resilience and crisis prevention.

●​ Strengthening support systems.

Steps and activities:

●​ Discussing techniques for staying in the present and working on reducing her

emotional reactivity to intrusive memories, and fostering acceptance.

●​ Beginning structured trauma-focused discussions using techniques like guided

imagery or safe disclosure methods to help her process past events at her own pace.

●​ Working with MI to create a plan for managing distressing thoughts, identifying early

warning signs of emotional distress, and implementing coping strategies to prevent

crisis situations. Also helping her create a grounding kit with strategies to implement

in situations when she does feel overwhelmed.

●​ Identifying supportive individuals (e.g., her mother, a support group, online

communities) who can offer emotional and practical support to MI.

Outcomes:

●​ MI starts processing her trauma in a controlled, supportive environment, reducing

emotional suppression and avoidance.

●​ She learns to manage distressing thoughts and flashbacks more effectively using

structured coping techniques.

●​ She has a structured safety plan in place for dealing with moments of crisis and

emotional distress.

●​ She identifies key sources of support and begins strengthening her interpersonal

relationships.