Adult and Child Case Histories

ADULT
CASE
HISTORY

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CASE HISTORY 1

SOCIO-DEMOGRAPHIC DATA

• Name: Mr. R

• Age: 34

• Date of Birth: 15/08/1989

• Sex: Male

• Education: Bachelor’s degree in Commerce

• Occupation: Unemployed (previously worked in the business field)

• Annual Income: Not applicable

• Marital Status: Single

• Residence: Urban, lives alone in an apartment

• Mother Tongue: Hindi

• Religion: Hindu

REFERRAL DETAILS

• Referral Source: Brought by a neighbor who noticed his erratic behavior.

• Informant Details:

o Name: Ms. S (neighbor)

o Relationship with Client: Acquaintance

o Adequacy: Adequate

o Reliability: Reliable

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PRESENTING COMPLAINTS

• According to Informant:

o Talks to himself loudly.

o Believes people are plotting against him.

o Neglects personal hygiene and has stopped going to work.

• According to Client:

o Admits to hearing voices that “tell him what to do.”

o Believes his neighbors are spying on him.

HISTORY OF PRESENTING ILLNESS (HOPI)

• Duration: 6 months

• Mode of Onset: Insidious

• Course: Deteriorating

Body of HOPI:

Mr. R, a 34-year-old male with a bachelor’s degree in Commerce, presented with a 6-month

history of psychotic symptoms, including auditory hallucinations, delusions of persecution,

and social withdrawal. The symptoms began insidiously, with mild paranoia and social

withdrawal, which gradually worsened over time. Initially, he experienced mild

suspiciousness, believing that his colleagues were talking about him behind his back.

However, these beliefs became more pronounced, and he began to believe that his neighbors

were spying on him and plotting against him.

Mr. R reported hearing voices that “tell him what to do” and comment on his actions. He

described the voices as male and female, often criticizing him and giving him commands. He
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admitted to following the commands of the voices, which led to erratic behavior, such as

talking to himself loudly and avoiding social interactions. He also reported feeling constantly

watched and believed that his neighbors had installed cameras in his apartment to monitor

him.

The symptoms have significantly impacted Mr. R’s daily functioning. He has stopped going

to work, neglected personal hygiene, and isolated himself from friends and family. His

neighbor, who brought him to the clinic, reported that he often stays indoors with the curtains

drawn, refusing to interact with anyone. He has also stopped taking care of his apartment,

which has become cluttered and unkempt.

Mr. R described feeling anxious and fearful most of the time, often unable to sleep due to the

voices and his belief that he is being watched. He admitted to feeling overwhelmed by his

symptoms and unable to control them. Despite recognizing that his beliefs and experiences

are unusual, he feels unable to seek help on his own, stating, “I don’t know who to trust…

everyone is against me.”

The onset of Mr. R’s symptoms appears to be closely linked to a stressful work environment

and social isolation. The initial paranoia and social withdrawal were triggered by workplace

stress, which exacerbated his underlying vulnerability to psychosis. Additionally, his

naturally introverted personality and lack of social support may have contributed to the

development of his condition.

Mr. R’s psychosis has severely impacted his personal and professional life. His inability to

work has led to financial difficulties, and his social withdrawal has isolated him from friends

and family. He described feeling lonely and disconnected from others, often wishing he could

return to his normal life but feeling trapped by his symptoms.

• Precipitating Factors: Stressful work environment and isolation.

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NEGATIVE HISTORY

• No history of substance abuse or medical illness.

MEDICAL HISTORY

• Illness: None.

• Operation: None.

• Accidents: None.

• Surgical Problem: None.

PAST PSYCHIATRIC HISTORY

• Dates: Not applicable.

• Duration: Not applicable.

• Symptoms: Not applicable.

• Diagnosis: Not applicable.

• Treatment: Not applicable.

FAMILY HISTORY

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Mr. R comes from a nuclear family of four members, including his parents and a younger

sister. His father, aged 60, is a retired government employee, and his mother, aged 58, is a

homemaker. His younger sister, aged 30, is married and lives with her family.

There is no family history of psychiatric illness or significant medical conditions. Both

parents are in good health, and the family environment is described as supportive. However,

Mr. R has become estranged from his family due to his erratic behavior and social

withdrawal. His parents and sister are unaware of the severity of his condition, as he has cut

off communication with them over the past few months.

PERSONAL HISTORY

• Date of Birth: 15/08/1989

• Place of Birth: Delhi, India

• Birth History: Full-term normal delivery.

• Delivery Type: Normal

• Birth Cry: Normal

• Mother’s Condition During Pregnancy: No complications.

• Postnatal History: Breastfed, no significant issues.

• Physical Health During Infancy: Healthy.

• Delay in Milestone Development: None.

o Motor: Achieved normally.

o Adaptive: Achieved normally.

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o Speech: Achieved normally.

o Social: Achieved normally.

• Neurotic Symptoms in Childhood: None reported.

• Night Terrors: None reported.

• Behavior Problems During Childhood: None reported.

• Habits During Childhood: Regular sleep and eating patterns.

• Childhood Health: No significant illnesses.

• Home Atmosphere During Childhood: Satisfactory.

• Emotional Problems in Adolescence: None reported.

• Home Atmosphere During Adolescence: Satisfactory.

• Parental Lack: Not elicited.

• Anomalous Family Situation: Not elicited.

EDUCATIONAL HISTORY

• Age of Beginning School: 5 years

• Special Abilities/Disabilities: None.

• Academic Performance: Average.

• Number of Friends: Few close friends.

• Relationship with Friends: Good.

• Co-curricular Activities: Interested in music and reading.

• Hobbies and Interests: Reading and listening to music.

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OCCUPATIONAL HISTORY

• Age of Starting Work: 24 years

• Work Record: Previously satisfactory, but currently unemployed.

• Past Job: Worked in the business field for over 10 years.

• Present Job: Unemployed.

• Job Satisfaction: Previously high, but currently not applicable.

Menstrual History:

• Not applicable (client is male).

Sexual Inclinations and Practice:

• Sexual Information Acquired Through: Not elicited.

• Masturbation/Sexual Fantasies: Not elicited.

• Homosexuality/Heterosexuality: Heterosexual.

• Sexual Problems if Any: Not elicited.

PREMORBID PERSONALITY

• Social Relations:

o Family: Previously close but currently estranged.

o Friends: Few close friends, though he has become withdrawn.

o Relatives: Cordial.

o Societies: Not applicable.

o Workmates: Previously good relationships, but currently no contact.

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• Intellectual Activities:

o Hobbies: Reading and listening to music.

o Interests: Business and finance.

o Memory: Good.

o Observation: Keen.

o Judgement: Previously sound, but currently impaired.

• Mood of Client:

o Generally stable but prone to anxiety.

• Character:

o Responsible but perfectionistic.

• Fantasy Life: Minimal daydreaming.

• Habits:

o Eating: Irregular.

o Alcohol Consumption: None.

o Self-Medication: None.

o Tobacco Consumption: None.

o Sleeping Patterns: Poor, often disrupted.

o Excretory Functions: Normal.

o Use of Other Recreational Drugs: None.

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MENTAL STATUS EXAMINATION

General Appearance and Behavior

• Appearance: Looking one’s age but disheveled.

• Level of Grooming: Shabbily dressed.

• Level of Cleanliness: Inadequate.

• Level of Consciousness: Fully conscious and alert.

• Mode of Entry: Brought using physical force (reluctant to come).

• Cooperativeness: Less than normal.

• Eye-to-Eye Contact: Not maintained.

• Psychomotor Activity: Increased restlessness (agitated due to paranoia).

• Empathy: Difficult to establish.

• Quality of Rapport: Poor.

• Gesturing: Odd (frequent hand movements).

• Posturing: Normal posture.

• Other Movements: Mannerisms (repetitive movements).

• Other Catatonic Phenomena: None (no automatic obedience, negativism, waxy

flexibility, echopraxia, or echolalia).

Speech

• Initiation: Speaks when spoken to.

• Reaction Time: Delayed.

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• Speed: Slow.

• Output: Decreased.

• Pressure of Speech: Absent.

• Volume: Normal.

• Tone: Monotonous.

• Manner: Normal.

• Relevance: Sometimes off target.

• Stream: Normal.

• Coherence: Some loosening of associations.

• Others: None (no rhyming, punning, echolalia, perseveration, or neologism).

• Sample of Speech: Responds with occasional irrelevant responses, e.g., “They are

watching me… I can’t trust anyone.”

• Impression: Speech partially intact (some loosening of associations).

Thought

• Tempo: Normal.

• Form: Adequate.

• Obsession: None.

• Compulsion: None.

• Thought Alienation Phenomena: Thought broadcasting (believes others can hear his

thoughts).

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• Thought Commentary: None.

• Thought Contents:

o Idea: Persecution, surveillance, and control.

o Overvalued Idea: None.

o Delusion: Delusions of persecution (believes neighbors are spying on him).

o Sample: “My neighbors have installed cameras in my apartment to monitor

me.”

• Impression: Thought not intact (delusions and thought broadcasting present).

Mood

• Subjective: “I feel anxious and scared all the time.”

• Objective: Anxious and fearful.

• Predominant Mood State: Anxious.

• Other Major Moods: Fearful.

• Range: Restricted.

• Reactivity: Non-reactive.

• Quality of Mood: Tense and fearful.

• Communicability: Poor.

• Lability: None.

• Appropriateness: Appropriate to thought content.

• Congruence: Mood congruent.

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• Emotional Expression: Blunted.

• Impression: Mood is congruent to affect.

Perception

• Hallucination: Auditory hallucinations (voices commenting on his actions).

• Illusion: None.

• Depersonalization: None.

• Déjà Vu Phenomena: None.

• Somatic Passivity: None.

• Special: None (no made acts).

• Impression: Perception not intact (auditory hallucinations present).

Cognitive Functions

• Attention: Normally aroused.

• Digit Forward: 5/5.

• Digit Backward: 3/5.

• Concentration: Normally sustained.

• 100-7 Test: 93, 86, 79, 72, 65 (completed without difficulty).

• 40-3 Test: 37, 34, 31, 28, 25 (completed without difficulty).

• 20-1 Test: 19, 18, 17, 16, 15 (completed without difficulty).

• Months Backwards: Completed without difficulty.

• Weekdays Backwards: Completed without difficulty.

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• Impression: Cognitive functions intact.

Orientation

• Time: Approximate time (knows day, date, month, and year).

• Place: Kind of place (knows he is in a clinic).

• Person: Self and close associates (recognizes himself and family members).

• Speech Sample: “Today is Tuesday, October 10th, 2023. I’m at the clinic for my

appointment. I came here with my neighbor. I know who I am, and I recognize my

family members.”

• Impression: Orientation to time, place, and person intact.

Memory

• Immediate: 3/3 objects recalled immediately (asked to remember three objects:

apple, table, and umbrella).

• Recent: Recalls last meal and visitors.

o “For breakfast, I had toast and tea. My neighbor accompanied me to the clinic

today.”

• Verbal Recall:

o After 5 minutes: 3/3 objects.

o After 10 minutes: 3/3 objects.

• Visual Recall: 3/3 objects recalled (shown a picture with a tree, a car, and a book).

• Remote: Recalls personal and impersonal events accurately.

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o “I was born in 1989. I also remember when the first man landed on the

moon—it was in 1969.”

• Impression: Memory intact.

Intelligence

• Comprehension: Understands simple and complex commands.

o “If I found a stamped, addressed envelope on the ground, I would mail it to

the address written on it.”

• Vocabulary: Good (can name common and uncommon objects).

• Arithmetic Ability: Adequate (can perform mental arithmetic).

• General Fund of Information:

o Literate: Knows the name of the Prime Minister, 5 rivers, cities, states, and

capitals of countries.

o Current Events: Aware of major current events.

▪ “I heard on the news that there was a major earthquake in Morocco

recently.”

• Impression: Intelligence average.

Abstraction

• Interpretation of Proverbs: Concrete.

o “A stitch in time saves nine” interpreted as “Sewing saves clothes.”

• Similarities Between Paired Objects: Concrete.

o “Apple and orange” interpreted as “Both are fruits.”

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• Dissimilarities Between Paired Objects: Concrete.

o “Book and TV” interpreted as “One is for reading, the other is for watching.”

• Impression: Abstraction is concrete.

Judgment

• Personal: Impaired (unable to plan for the future due to preoccupation with

delusions).

o “If I ran out of my medication, I would wait until my next appointment to ask

for more.”

• Social: Impaired (disregards social norms due to paranoia).

o “If I saw someone stealing in a store, I would ignore it because it’s not my

problem.”

• Test: Impaired (predicts negative outcomes in imaginary situations).

o “If I found a stamped letter on the ground, I would throw it away because it’s

not mine.”

• Impression: Judgment not intact.

Insight

• Awareness of Abnormal Behavioral/Experience: Yes.

• Attribution to Physical Causes: No.

• Recognition of Personal Responsibility: Yes.

• Willingness to Take Treatment: Yes.

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• Grade: 2 (Slight awareness of being sick and needing help, denying at the same

time).

• Motivation/Willingness for Treatment: Motivated but feels hopeless about

improvement.

DIAGNOSTIC FORMULATION

• Major Diagnosis: Psychosis (likely schizophrenia).

• Differential Diagnosis: Delusional disorder, substance-induced psychosis.

• Associated Diagnoses: None.

PSYCHOTHERAPY AND MANAGEMENT

• Medications: Antipsychotics (e.g., Risperidone).

• Therapy: Cognitive Behavioral Therapy (CBT) for psychosis.

• Social Support: Vocational rehabilitation and family counseling.

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CASE HISTORY 2

SOCIO-DEMOGRAPHIC DATA

Name: Mrs. S

Age: 38 years

Sex: Female

Education: High School Graduate

Occupation: Homemaker

Annual Income: Dependent on spouse

Marital Status: Married

Residence: Rural

Mother Tongue: Hindi

Religion: Hindu

REFERRAL DETAILS

Referred by a local general physician due to persistent low mood, loss of interest, and

suicidal thoughts.

INFORMANT DETAILS

Name: Mr. S (Husband)

Relationship with client: Husband

Acquaintance: Lives with patient

Adequacy: Good

Reliability: High

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PRESENTING COMPLAINTS

• Persistent sadness – 9 months

• Loss of interest in household activities – 8 months

• Fatigue and lack of energy – 7 months

• Sleep disturbances – 6 months

• Suicidal thoughts – 1 month

HISTORY OF PRESENTING ILLNESS

The patient first noticed symptoms six years ago when he developed a persistent fear of

germs and contamination. He began washing his hands frequently, initially thinking it was a

hygiene concern. However, over time, his need to wash increased, and he started avoiding

touching public surfaces or shaking hands with others. Around five years ago, he developed

repeated checking behaviors, such as ensuring doors were locked and gas stoves were turned

off multiple times before leaving home. This significantly increased the time he took to

complete daily tasks. He became distressed if he could not perform these rituals, experiencing

heightened unease.

Four years ago, he started experiencing unwanted thoughts about harming his loved ones,

even though he had no intention of acting on them. This led to immense guilt and further

reinforced his need to perform certain actions, as he believed they would help him feel better.

His symptoms worsened over the past two years, severely affecting his ability to function at

work. His productivity declined as he spent extended periods engaged in repetitive behaviors.

His wife reported that he would repeatedly ask for reassurance about cleanliness and safety,

leading to strain in their relationship. He finally sought help when he realized his behaviors

were beyond his control and causing distress to his family.

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In recent months, his behaviors have extended to his personal hygiene and grooming routines.

He now spends an excessive amount of time showering, often repeating the process multiple

times a day if he feels he has come into contact with something he considers dirty. He has

also developed specific routines for dressing, such as repeatedly washing and rewashing his

clothes or avoiding certain outfits he feels are unclean. These behaviors have caused

significant delays in his daily schedule, often making him late for work or social

commitments. His wife has noted that he becomes visibly upset if his routines are interrupted

or if he is unable to complete them to his satisfaction.

The unwanted thoughts have also become more frequent and distressing, often involving

vivid mental images of harm coming to his family members or himself. These thoughts are

inconsistent with his values and cause him significant distress. To cope, he has developed

new habits, such as repeating specific phrases or prayers in his mind a set number of times,

which he believes will prevent harm from occurring. However, these habits provide only

temporary relief, and the unwanted thoughts quickly return, creating a cycle of unease and

repetitive actions.

His symptoms have also begun to affect his sleep. He often stays up late into the night

performing cleaning rituals or checking locks and appliances, leaving him exhausted the next

day. His wife has observed that he appears increasingly tired and irritable, and he has

admitted to feeling overwhelmed by the constant mental and physical demands of his

behaviors. Despite his exhaustion, he finds it difficult to relax or engage in leisure activities,

as his mind is preoccupied with fears of contamination or harm. This has further contributed

to his sense of isolation and has made it challenging for him to connect with his family or

enjoy moments of rest.

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The patient has been socially withdrawn since his teenage years, avoiding group activities

and preferring solitary tasks. During his school years, he was often hesitant to ask questions

in class or participate in discussions, fearing he would be ridiculed. His classmates perceived

him as shy, but his parents initially considered it a normal personality trait rather than

something to be concerned about. During his college years, his unease in social situations

worsened as he faced increased academic and social expectations. He struggled to participate

in presentations, avoided making eye contact, and often skipped classes where he was

required to engage in discussions. When forced into social situations, he experienced physical

symptoms such as excessive sweating, trembling, and a racing heart. He started to overthink

every interaction, fearing that others were constantly judging him. As a result, he withdrew

further, spending most of his time in his hostel room or at home during vacations.

Over the past year, his academic performance has declined due to his inability to participate

in group projects and oral examinations. His avoidance of social situations increased, and he

began making excuses to skip social events, fearing he might embarrass himself. He

expressed deep distress about his inability to communicate effectively and felt inferior to his

peers. He also admitted to feeling isolated but was unable to initiate conversations or

maintain friendships due to his overwhelming fear of being judged negatively. His family

initially dismissed his struggles, attributing them to nervousness or a lack of confidence.

However, when his college counselor noted his difficulties and suggested seeking help, his

parents decided to take action. He reports no history of substance use, major stressors, or

medical illnesses. However, his mother has a history of social withdrawal, though she was

never formally evaluated for it.

The patient was reportedly functioning well until nine months ago when she started

experiencing persistent sadness, which she initially attributed to increasing household

burdens and financial difficulties. As the eldest daughter-in-law in a joint family, she was

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responsible for numerous domestic duties, caring for children, and managing family

expectations. She initially dismissed her symptoms, attributing them to stress and exhaustion.

Over the next few months, she lost interest in routine activities, including cooking and

interacting with family members. She stopped participating in religious and community

events, which had previously been a source of joy. Her energy levels declined significantly,

making it difficult for her to complete daily chores. She felt overwhelmed but was unable to

express her distress openly due to fear of being judged by her in-laws and extended family.

Her sleep became disturbed, and she began waking up in the early hours of the morning,

unable to fall back asleep. Her appetite reduced significantly, leading to noticeable weight

loss. She often complained of body aches and headaches, for which she frequently visited

local healers and religious practitioners, believing she was under some spiritual influence.

However, no physical cause was found, and her symptoms persisted. One month ago, she

began experiencing recurrent thoughts of death and suicide. She confided in her husband that

she felt like a burden to the family and wished to end her life. She also mentioned feeling

worthless, as she believed she had failed in fulfilling her family responsibilities. Her husband

became alarmed when he found her sitting alone for long hours, weeping uncontrollably.

Concerned about her worsening condition, he took her to a local doctor, who referred her for

further evaluation.

There was no prior history of similar episodes, substance use, or major life stressors apart

from family-related conflicts. A family history revealed that her maternal aunt had suffered

from a similar condition but never received formal treatment.

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NEGATIVE HISTORY

• No history of manic or psychotic symptoms

• No history of substance use

• No known chronic medical illness

MEDICAL HISTORY

No significant past medical illness, surgeries, or accidents.

PAST PSYCHIATRIC HISTORY

No prior psychiatric hospitalizations or treatments.

FAMILY HISTORY

• History of untreated depression in a maternal relative.

• No history of bipolar disorder or schizophrenia.

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PERSONAL HISTORY

Date of Birth: 12th June 1985

Place of Birth: Jaipur, Rajasthan, India

Birth history: Full-term delivery

Delivery type: Normal vaginal delivery

Birth cry: Immediate and normal

Mother’s condition during pregnancy: No significant complications reported during

pregnancy. Mother did not have gestational diabetes, hypertension, or infections.

Postnatal history: No postnatal complications reported. Mother and baby were discharged

within 2 days of delivery.

Physical health during infancy: Generally healthy with no major illnesses. No history of

recurrent infections, feeding difficulties, or hospitalization during infancy.

Delay in milestone development:

• Motor: No significant delay. Started walking independently by 12 months.

• Adaptive: No significant delay. Able to perform age-appropriate self-care tasks (e.g.,

feeding, dressing) on time.

• Speech: No significant delay. Started speaking single words by 12 months and simple

sentences by 2 years.

• Social: No significant delay. Able to interact with family members and peers

appropriately during early childhood.

Neurotic symptoms in childhood: None reported. No history of excessive anxiety, phobias,

or obsessive-compulsive behaviors during childhood.

Night terrors: None reported.

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Behavior problems during childhood: None reported. No history of aggression, defiance, or

conduct problems during childhood.

Habits during childhood: No significant habits reported (e.g., no thumb-sucking, nail-biting,

or bedwetting).

Childhood health: Generally healthy with no chronic illnesses. Experienced common

childhood illnesses (e.g., cold, fever) but no major health concerns.

Home atmosphere during childhood: Satisfactory. The patient grew up in a stable and

supportive family environment. Parents were attentive and caring.

Emotional problems in adolescence: None reported. No history of running away,

delinquency, smoking, drug use, or identity problems.

Home atmosphere during adolescence: Satisfactory. The patient had a supportive family

environment during adolescence.

Parental lack: None reported. Both parents were involved and supportive.

Anomalous family situation: None reported. The family was stable and intact.

EDUCATIONAL HISTORY

Age of beginning school: 5 years old

Special abilities/disabilities: No special abilities or disabilities reported. The patient was an

average student with no significant learning difficulties.

Academic performance: Average. The patient consistently scored average grades throughout

school.

Number of friends: Moderate. The patient had a small group of close friends during school

years.

Relationship with friends: Friendly and supportive. The patient maintained good

relationships with her peers.

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Co-curricular activities: Minimal participation. The patient occasionally participated in

school events but showed little interest in sports or arts.

Hobbies and interests: Enjoyed reading and gardening.

OCCUPATIONAL HISTORY

Age of starting work: Not applicable (patient is a homemaker).

Work record: Not applicable.

Past job: None.

Present job: Homemaker.

Job satisfaction: Initially satisfied but has become less so due to depression.

MENSTRUAL HISTORY

Age of Menarche: 13 years old

Regularity/duration: Regular cycles, 28-day cycle, duration of 5 days.

Amount of physical pain: Mild to moderate menstrual cramps.

Emotional problems if any: None reported.

SEXUAL INCLINATIONS AND PRACTICE

Sexual information acquired through: Peers and informal sources (e.g., friends, internet).

The patient did not receive formal sexual education.

Masturbation/sexual fantasies: Occasional masturbation reported, which she considers

normal. No excessive or compulsive behavior reported.

Homosexuality/heterosexuality: Heterosexual orientation.

Sexual problems if any: Reduced libido due to depression.

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MARITAL HISTORY

Spouse age: 40 years old

Duration of marriage: 15 years

Occupation: Farmer

Personality: Supportive but traditional.

Compatibility: Initially good but has become strained due to the patient’s depression.

PRE-MORBID PERSONALITY

Social relations with:

• Family: Close relationship with parents and siblings.

• Friends: Friendly and supportive relationships with a small group of friends.

• Relatives: Maintained casual relationships with extended family.

• Societies: No active participation in social groups or community activities.

• Workmates: Not applicable (patient is a homemaker).

Intellectual activities like:

• Hobbies: Enjoyed reading and gardening.

• Interests: Limited interests outside of her hobbies.

• Memory: No significant memory issues reported prior to depression.

• Observation: Generally observant.

• Judgement: Fair judgment in everyday matters but became impaired due to

depression.

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Mood of client:

• Bright/cheerful: Occasionally.

• Despondent: Frequently, especially in the context of depression.

• Optimistic: Rarely.

• Pessimistic: More often, particularly in recent months.

• Self-depreciative: Occasionally, with feelings of inadequacy related to her

depression.

• Satisfied: Rarely.

• Stable: Generally stable but with increasing mood fluctuations due to depression.

• Unstable: Became more unstable as depression worsened.

Character:

• Attitude to work and responsibility: Responsible but became neglectful due to

depression.

• Interpersonal relationships: Friendly but became strained due to depression.

• Standards in religious/social/health matters: Moderate. The patient adhered to

basic religious practices but was not deeply involved. Social and health standards

were average.

Fantasy life:

• Frequency and content of day dreaming: Occasionally engaged in daydreaming,

often about escaping her current situation or achieving success.

Habits:

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• Eating: Reduced appetite due to depression.

• Alcohol consumption: No history of alcohol use.

• Self-medication: None reported.

• Tobacco consumption: No history of tobacco use.

• Sleeping patterns: Disturbed sleep due to depression (early morning awakenings).

• Excretory functions: No significant issues reported.

• Use of other recreational drugs: None reported.

GENERAL APPEARANCE AND BEHAVIOUR

Appearance: Looking older than her age (due to fatigue and neglect of self-care).

Level of Grooming: Shabbily dressed.

Level of Cleanliness: Inadequate.

Level of consciousness: Fully conscious and alert.

Mode of entry: Came willingly.

Cooperativeness: Normal.

Eye-to-eye Contact: Difficult to maintain.

Psychomotor activity: Decreased (slowed movements and speech).

Empathy: Difficult to establish.

Quality of rapport: Poor.

Gesturing: Minimal.

Posturing: Normal posture.

Other movements: None observed (no mannerisms, stereotypes, tremors, EPS, AIMS, or

perseveration).

Other Catatonic Phenomena: None observed.

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SPEECH

Initiation: Speaks when spoken to.

Reaction time: Delayed.

Speed: Slow.

Output: Decreased.

Pressure of Speech: Absent.

Volume: Decreased.

Tone: Monotonous.

Manner: Normal.

Relevance: Fully relevant.

Stream: Normal.

Coherence: Fully coherent.

Others: None observed (no rhyming, punning, echolalia, perseveration, or neologism).

Sample of speech (in response to open-ended questions):

• "I feel so tired all the time. I can’t do anything anymore. I just want to sleep and not

wake up."

THOUGHT

Tempo: Retarded thinking.

Form: Adequate.

Obsession: None observed.

Compulsion: None observed.

Thought alienation phenomena: None observed.

Thought contents:

• Worthlessness: Feels like a burden to her family.

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• Hopelessness: Believes her situation will never improve.

• Guilt: Feels guilty for not fulfilling her responsibilities.

• Suicidal Ideas: Recurrent thoughts of death and suicide.

Example: "I’m useless. My family would be better off without me."

IMPRESSION: Not intact

MOOD

Subjective: Sad and hopeless.

Objective:

• Predominant mood state: Depressed.

• Other major moods: Anxious, irritable.

• Range: Restricted.

• Reactivity: Reduced.

• Quality of mood: Dysphoric.

• Communicability: Difficult.

• Lability: Present (frequent mood swings).

• Appropriateness: Appropriate.

• Congruence: Congruent.

• Emotional expression: Blunted.

IMPRESSION: mood is congruent with affect

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PERCEPTION

Hallucination: None observed.

Illusion: None observed.

Depersonalization: None reported.

Déjà vu phenomena: None reported.

Other perceptual disturbances: None observed.

IMPRESSION: perception intact

COGNITIVE FUNCTIONS

Attention:

• Arousal: Normally aroused.

• Digit forward: The patient was able to repeat 5 digits forward correctly.

• Digit backward: The patient was able to repeat 4 digits backward correctly.

Concentration:

• Sustained: Normally sustained but with some difficulty due to distractibility.

• 100 – 7 test:

o 100 – 7 = 93 (correct)

o 93 – 7 = 86 (correct)

o 86 – 7 = 79 (correct)

o 79 – 7 = 72 (correct)

o 72 – 7 = 65 (correct)

• 40 – 3 test:

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o 40 – 3 = 37 (correct)

o 37 – 3 = 34 (correct)

o 34 – 3 = 31 (correct)

o 31 – 3 = 28 (correct)

o 28 – 3 = 25 (correct)

• 20 – 1 test:

o 20 – 1 = 19 (correct)

o 19 – 1 = 18 (correct)

o 18 – 1 = 17 (correct)

o 17 – 1 = 16 (correct)

o 16 – 1 = 15 (correct)

• Names of months (backwards): The patient was able to name the months backwards

with some hesitation but completed the task correctly.

• Names of weekdays (backwards): The patient was able to name the weekdays

backwards with some hesitation but completed the task correctly.

IMPRESSION: attention and concentration are intact

ORIENTATION

Time: Fully oriented (correctly identified the date, day, month, and year).

Place: Fully oriented (correctly identified the hospital and city).

Person: Fully oriented (correctly identified herself, family members, and hospital staff).

IMPRESSION: orientation to time, place, and person intact

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MEMORY

Immediate memory: Intact (digit forward and backward tests).

Recent memory:

• Recent happenings: The patient was able to recall her last meal and the fact that she

was brought to the hospital by her husband.

• Verbal recall:

o After 5 minutes: The patient was able to recall 3 out of 5 unrelated objects

(e.g., apple, table, river).

o After 10 minutes: The patient was able to recall 2 out of 5 unrelated objects.

• Visual recall: The patient was shown 3 unrelated objects (e.g., pen, book, chair) and

was able to recall 2 out of 3 after 5 minutes and 1 out of 3 after 10 minutes.

Remote memory: Intact. The patient was able to recall significant personal and

impersonal events.

IMPRESSION: memory intact

INTELLIGENCE

Comprehension:

• Simple commands: The patient was able to follow simple commands (e.g., "Close

your eyes," "Raise your hand").

• Complex commands: The patient had difficulty following complex commands (e.g.,

"Take this paper in your left hand, fold it in half, and place it on the table").

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Vocabulary:

• Common objects: The patient was able to name common objects (e.g., pen, chair,

book) without difficulty.

• Uncommon objects: The patient struggled to name uncommon objects (e.g.,

stethoscope, microscope).

• Parts of objects: The patient was able to identify parts of objects (e.g., "What is the

part of a chair you sit on?" Answer: "Seat").

Arithmetic ability:

• Mental arithmetic: The patient was able to perform simple calculations (e.g., 5 + 7 =

12) but struggled with more complex problems (e.g., 23 – 8 = 15).

General fund of information:

• Literate: The patient is literate and has completed high school.

o Name of the Prime Minister: The patient was able to name the current Prime

Minister correctly.

o 5 rivers, cities, or states: The patient was able to name 5 rivers (e.g., Ganga,

Yamuna, Brahmaputra, Godavari, Krishna) and 5 cities (e.g., Delhi, Mumbai,

Chennai, Kolkata, Kochi).

o Capitals of countries: The patient was able to name the capitals of a few

countries (e.g., India – New Delhi, USA – Washington D.C., UK – London).

o Current events (Major): The patient was able to recall some major current

events (e.g., recent elections, natural disasters).

IMPRESSION: intelligence average

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ABSTRACTION

Abstraction: Concrete.

Interpretation of proverbs:

• Proverb: "People who live in glass houses shouldn’t throw stones."

o Patient’s interpretation: "If you live in a glass house, stones will break it."

(Concrete interpretation, no abstract understanding.)

• Proverb: "A stitch in time saves nine."

o Patient’s interpretation: "If you sew something, it won’t tear." (Concrete

interpretation, no abstract understanding.)

Similarities between paired objects:

• Example: "How are an apple and an orange alike?"

o Patient’s response: "Both are fruits." (Correct but concrete.)

• Example: "How are a book and a movie alike?"

o Patient’s response: "Both have stories." (Correct but concrete.)

Dissimilarities between paired objects:

• Example: "How are a car and a bicycle different?"

o Patient’s response: "A car has an engine, and a bicycle doesn’t." (Correct but

concrete.)

• Example: "How are a river and a lake different?"

o Patient’s response: "A river flows, and a lake doesn’t." (Correct but

concrete.)

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IMPRESSION: abstraction is concrete

JUDGMENT

Judgment: Impaired.

• Personal: Poor sense of personal capability and worth. No clear plans for the future.

• Social: Impaired sense of socially and culturally acceptable behavior (e.g., suicidal

thoughts).

• Test: When asked how she would respond to an imaginary situation (e.g., "What

would you do if you found a stamped, addressed envelope on the street?"), the patient

responded, "I would throw it away because I don’t care about anything anymore."

(Impaired judgment.)

IMPRESSION: judgement not intact

Insight

• Awareness of Abnormal Behavior/Experience: Yes.

• Attribution to Physical Causes: No.

• Recognition of Personal Responsibility: Yes.

• Willingness to Take Treatment: Yes.

• Grade: 5 (Intellectual insight: Aware of being ill and that symptoms are due to

irrational thoughts, but struggles to apply this to current experiences).

DIAGNOSTIC FORMULATION

• Major Diagnosis: Major Depressive Disorder, Moderate-Severe (ICD-10: F32.2).

• Differential Diagnosis:

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o Adjustment Disorder with Depressed Mood.

o Persistent Depressive Disorder.

PSYCHOTHERAPY AND MANAGEMENT

1. Pharmacotherapy:

o SSRIs (e.g., Sertraline): First-line treatment for depression.

o Benzodiazepines (e.g., Clonazepam): Short-term use for anxiety and sleep

disturbances.

2. Psychotherapy:

o Cognitive Behavioral Therapy (CBT): To address negative thought patterns

and improve coping skills.

o Supportive Therapy: To provide emotional support and validation.

3. Lifestyle Modifications:

o Encourage regular exercise, balanced diet, and adequate sleep.

o Address work-life balance and stress management.

4. Family Psychoeducation:

o Educate family members about depression and involve them in the treatment

process.

PROGNOSIS

• Good Prognostic Factors: High motivation for treatment, supportive family, and no

comorbid psychiatric or medical conditions.

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• Potential Challenges: Chronicity of symptoms (9 months) and impaired judgment

may require longer-term intervention.

CONCLUSION

Mrs. S presents with symptoms consistent with Major Depressive Disorder, characterized by

persistent sadness, loss of interest, fatigue, sleep disturbances, and suicidal thoughts. A

combination of pharmacotherapy (SSRIs) and psychotherapy (CBT) is recommended, along

with lifestyle modifications and family involvement. With appropriate treatment, her

prognosis is favorable.

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CASE HISTORY 3

SOCIO-DEMOGRAPHIC DATA

• Name: Mr. Y

• Age: 29

• Date of Birth: 14/09/1994

• Sex: Male

• Education: Bachelor’s degree in Business Administration

• Occupation: Business professional

• Annual Income: Not specified

• Marital Status: Single

• Residence: Urban, lives with parents

• Mother Tongue: Gujarati

• Religion: Hindu

REFERRAL DETAILS

• Referral Source: Self-referred after struggling with work-related social interactions.

• Informant Details:

o Name: Mrs. Y (mother)

o Relationship with Client: Mother

o Adequacy: Adequate

o Reliability: Reliable

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PRESENTING COMPLAINTS

• According to Informant:

o Avoids social gatherings and public speaking.

o Appears excessively anxious in social situations.

o Frequently complains of physical symptoms like sweating and trembling.

• According to Client:

o Feels intense fear of being judged or humiliated in social settings.

o Avoids eye contact and struggles to speak in groups.

HISTORY OF PRESENTING ILLNESS (HOPI)

• Duration: 5 years

• Mode of Onset: Insidious

• Course: Continuous

Body of HOPI:

Mr. Y, a 29-year-old male with a bachelor’s degree in Business Administration, presented

with a 5-year history of intense fear and avoidance of social situations. The symptoms began

during his final year of college when he was required to present a project in front of a large

audience. He described feeling overwhelmingly anxious during the presentation, with

physical symptoms such as sweating, trembling, and a racing heart. Despite preparing

extensively, he struggled to speak clearly and felt as though everyone was judging him. This

experience left him deeply embarrassed and fearful of similar situations.

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Following this incident, Mr. Y began to avoid social gatherings, group discussions, and public

speaking. He reported excessive worry about being judged or humiliated in social

interactions, even with familiar people. This fear extended to everyday situations, such as

speaking to colleagues, attending meetings, or eating in public. He described feeling as

though others were constantly evaluating him, leading to intense self-consciousness and

discomfort.

Physical symptoms of anxiety became a regular occurrence for Mr. Y. He reported

palpitations, sweating, and nausea when anticipating or facing social situations. These

symptoms were often so severe that he would avoid social interactions altogether. For

example, he declined invitations to office parties, avoided team meetings, and even skipped

family gatherings to prevent the discomfort of being around others.

The avoidance behaviors significantly impacted Mr. Y’s professional life. As a business

administration graduate, his job required frequent interactions with colleagues and clients.

However, he struggled to participate in meetings or network with others, often making

excuses to avoid these situations. This led to missed opportunities for career advancement

and strained relationships with his coworkers. He described feeling stuck in his current role,

unable to progress due to his anxiety.

Mr. Y’s social life also suffered as a result of his condition. He avoided social gatherings,

preferring to spend time alone or with close family members. He reported having few friends

and described himself as a “loner.” His parents noted that he had become increasingly

isolated over the years, often spending hours in his room reading or listening to music.

Despite the significant impact on his life, Mr. Y had never sought treatment before. He

attributed his symptoms to shyness and believed that he could overcome them on his own.

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However, as his condition worsened, he began to feel hopeless and frustrated. He described

feeling trapped by his anxiety, stating, “I want to be normal, but I don’t know how.”

• Precipitating Factors: Stressful college presentation and lack of social confidence.

NEGATIVE HISTORY

• No history of substance abuse or medical illness.

MEDICAL HISTORY

• Illness: None.

• Operation: None.

• Accidents: None.

• Surgical Problem: None.

PAST PSYCHIATRIC HISTORY

• Dates: Not applicable.

• Duration: Not applicable.

• Symptoms: Not applicable.

• Diagnosis: Not applicable.

• Treatment: Not applicable.

FAMILY HISTORY

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Mr. Y comes from a nuclear family of four members, including his parents and a younger

sister. His father, aged 58, is a retired government employee, and his mother, aged 55, is a

homemaker. His younger sister, aged 25, is employed as a teacher and lives separately with

her family.

There is no family history of psychiatric illness or significant medical conditions. Both

parents are in good health and have been supportive of Mr. Y, though they are unaware of the

severity of his social anxiety. The family environment is described as warm and nurturing,

with open communication. However, Mr. Y has not shared the extent of his anxiety and

avoidance behaviors with his family, as he fears they may not fully understand his condition.

PERSONAL HISTORY

• Date of Birth: 14/09/1994

• Place of Birth: Ahmedabad, Gujarat

• Birth History: Full-term normal delivery.

• Delivery Type: Normal

• Birth Cry: Normal

• Mother’s Condition During Pregnancy: No complications.

• Postnatal History: Breastfed, no significant issues.

• Physical Health During Infancy: Healthy.

• Delay in Milestone Development: None.

o Motor: Achieved normally.

o Adaptive: Achieved normally.

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o Speech: Achieved normally.

o Social: Achieved normally.

• Neurotic Symptoms in Childhood: Shyness and fear of strangers.

• Night Terrors: None reported.

• Behavior Problems During Childhood: None reported.

• Habits During Childhood: Regular sleep and eating patterns.

• Childhood Health: No significant illnesses.

• Home Atmosphere During Childhood: Satisfactory.

• Emotional Problems in Adolescence: None reported.

• Home Atmosphere During Adolescence: Satisfactory.

• Parental Lack: Not elicited.

• Anomalous Family Situation: Not elicited.

EDUCATIONAL HISTORY

• Age of Beginning School: 5 years

• Special Abilities/Disabilities: None.

• Academic Performance: Average.

• Number of Friends: Few close friends.

• Relationship with Friends: Good.

• Co-curricular Activities: Interested in reading and music.

• Hobbies and Interests: Reading and listening to music.

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OCCUPATIONAL HISTORY

• Age of Starting Work: 23 years

• Work Record: Satisfactory.

• Past Job: Business executive at a mid-sized firm.

• Present Job: Business professional at a reputed company.

• Job Satisfaction: Previously high, but currently affected by anxiety.

Menstrual History:

• Not applicable (client is male).

Sexual Inclinations and Practice:

• Sexual Information Acquired Through: Not elicited.

• Masturbation/Sexual Fantasies: Not elicited.

• Homosexuality/Heterosexuality: Heterosexual.

• Sexual Problems if Any: Not elicited.

PREMORBID PERSONALITY

• Social Relations:

o Family: Close but hesitant to share his struggles.

o Friends: Few close friends, though he has become more withdrawn.

o Relatives: Cordial.

o Societies: Not applicable.

o Workmates: Friendly but avoids socializing due to anxiety.

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• Intellectual Activities:

o Hobbies: Reading and listening to music.

o Interests: Business and finance.

o Memory: Good.

o Observation: Keen.

o Judgement: Sound.

• Mood of Client:

o Generally stable but prone to anxiety.

• Character:

o Responsible but perfectionistic.

• Fantasy Life: Minimal daydreaming.

• Habits:

o Eating: Regular.

o Alcohol Consumption: None.

o Self-Medication: None.

o Tobacco Consumption: None.

o Sleeping Patterns: Generally regular, but disrupted during stressful periods.

o Excretory Functions: Normal.

o Use of Other Recreational Drugs: None.

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MENTAL STATUS EXAMINATION

General Appearance and Behavior

Appearance: Looking one’s age.

Level of Grooming: Normal.

Level of Cleanliness: Adequate.

Level of Consciousness: Fully conscious and alert.

Mode of Entry: Came willingly.

Cooperativeness: Normal.

Eye-to-Eye Contact: Difficult.

Psychomotor Activity: Normal.

Empathy: Spontaneous.

Quality of Rapport: Good.

Gesturing: Normal.

Posturing: Normal posture.

Other Movements: None (no mannerisms, stereotypes, tremors, EPS, AIMS, or

perseveration).

Other Catatonic Phenomena: None (no automatic obedience, negativism, waxy flexibility,

echopraxia, or echolalia).

Speech

Initiation: Speaks when spoken to.

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Reaction Time: Delayed.

Speed: Normal.

Output: Decreased.

Pressure of Speech: Absent.

Volume: Soft.

Tone: Monotonous.

Manner: Normal.

Relevance: Fully relevant.

Stream: Normal.

Coherence: Fully coherent.

Others: None (no rhyming, punning, echolalia, perseveration, or neologism).

Sample of Speech: Responds briefly and hesitantly to open-ended questions, e.g., “I get

nervous when I have to talk to people… I’m afraid they’ll judge me.”

Impression: Speech intact.

Thought

Tempo: Normal.

Form: Adequate.

Obsession: None.

Compulsion: None.

Thought Alienation Phenomena: None (no thought insertion, withdrawal, or broadcast).

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Thought Commentary: None.

Thought Contents:

Idea: Fear of social judgment, embarrassment, and humiliation.

Overvalued Idea: None.

Delusion: None.

Example: “I feel like everyone is watching me and judging me.”

Impression: Thought is intact.

Mood

Subjective: “I feel anxious and nervous around people.”

Objective: Anxious and apprehensive.

Predominant Mood State: Anxious.

Other Major Moods: None.

Range: Restricted.

Reactivity: Reactive.

Quality of Mood: Anxious and tense.

Communicability: Good.

Lability: None.

Appropriateness: Appropriate to thought content.

Congruence: Mood congruent.

Emotional Expression: Normal.

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Impression: Mood is congruent to affect.

Perception

Hallucination: None.

Illusion: None.

Depersonalization: None.

Déjà Vu Phenomena: None.

Somatic Passivity: None.

Special: None (no made acts).

Impression: Perception intact

Cognitive Functions

Attention: Normally aroused.

Digit Forward: 5/5.

Digit Backward: 4/5.

Concentration: Normally sustained.

100-7 Test: 93, 86, 79, 72, 65 (completed without difficulty).

40-3 Test: 37, 34, 31, 28, 25 (completed without difficulty).

20-1 Test: 19, 18, 17, 16, 15 (completed without difficulty).

Months Backwards: Completed without difficulty.

Weekdays Backwards: Completed without difficulty.

Impression: Cognitive functions intact

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Orientation

Time: Approximate time (knows day, date, month, and year).

Place: Kind of place (knows he is in a clinic).

Person: Self and close associates (recognizes himself and family members).

Speech Sample: “Today is Tuesday, October 10th, 2023. I’m at the clinic for my appointment.

I came here with my mother. I know who I am, and I recognize my family members.”

Impression: Orientation to time, place, and person intact.

Memory

Immediate: 3/3 objects recalled immediately (asked to remember three objects: apple, table,

and umbrella).

Recent: Recalls last meal and visitors.

“For breakfast, I had toast and tea. My mother accompanied me to the clinic today.”

Verbal Recall:

After 5 minutes: 3/3 objects.

After 10 minutes: 3/3 objects.

Visual Recall: 3/3 objects recalled (shown a picture with a tree, a car, and a book).

Remote: Recalls personal and impersonal events accurately.

“I was born in 1994. I also remember when the first man landed on the moon—it was in

1969.”

Impression: Memory intact.

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Intelligence

Comprehension: Understands simple and complex commands.

“If I found a stamped, addressed envelope on the ground, I would mail it to the address

written on it.”

Vocabulary: Good (can name common and uncommon objects).

Arithmetic Ability: Adequate (can perform mental arithmetic).

General Fund of Information:

Literate: Knows the name of the Prime Minister, 5 rivers, cities, states, and capitals of

countries.

Current Events: Aware of major current events.

“I heard on the news that there was a major earthquake in Morocco recently.”

Impression: Intelligence average.

Abstraction

Interpretation of Proverbs: Concrete.

“A stitch in time saves nine” interpreted as “Sewing saves clothes.”

Similarities Between Paired Objects: Concrete.

“Apple and orange” interpreted as “Both are fruits.”

Dissimilarities Between Paired Objects: Concrete.

“Book and TV” interpreted as “One is for reading, the other is for watching.”

Impression: Abstraction is concrete

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Judgment

Personal: Intact (able to plan for the future).

“If I ran out of my medication, I would wait until my next appointment to ask for more.”

Social: Impaired (avoids social situations due to fear of judgment).

“If I saw someone stealing in a store, I would ignore it because it’s not my problem.”

Test: Impaired (predicts negative outcomes in social situations).

“If I found a stamped letter on the ground, I would throw it away because it’s not mine.”

Impression: Judgment not intact.

Insight

Awareness of Abnormal Behavioral/Experience: Yes.

Attribution to Physical Causes: No.

Recognition of Personal Responsibility: Yes.

Willingness to Take Treatment: Yes.

Grade: 5 (Intellectual insight: Awareness of being ill and that the symptoms are due to

irrational thoughts).

Motivation/Willingness for Treatment: Motivated and willing to engage in therapy.

DIAGNOSTIC FORMULATION

Major Diagnosis: Social Anxiety Disorder (Social Phobia).

Differential Diagnosis: Generalized Anxiety Disorder, Avoidant Personality Disorder.

Associated Diagnoses: None.

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PSYCHOTHERAPY AND MANAGEMENT

Medications: Selective Serotonin Reuptake Inhibitors (SSRIs) (e.g., Sertraline).

Therapy: Cognitive Behavioral Therapy (CBT) with exposure therapy.

Social Support: Group therapy and social skills training.

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CASE HISTORY 4

SOCIO-DEMOGRAPHIC DATA

• Name: Ms. B

• Age: 27

• Date of Birth: 25/11/1996

• Sex: Female

• Education: Master’s degree in Marketing

• Occupation: Marketing professional

• Annual Income: Not specified

• Marital Status: Single

• Residence: Urban, lives with a roommate

• Mother Tongue: Tamil

• Religion: Hindu

REFERRAL DETAILS

• Referral Source: Self-referred after experiencing recurrent panic attacks.

• Informant Details:

o Name: None (self-referred)

o Relationship with Client: Self

o Adequacy: Adequate

o Reliability: Reliable

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PRESENTING COMPLAINTS

• According to Client:

o Recurrent panic attacks characterized by intense fear, palpitations, and

shortness of breath.

o Fear of having another panic attack, leading to avoidance of certain situations.

o Reports physical symptoms like sweating, trembling, and dizziness during

attack

HISTORY OF PRESENTING ILLNESS (HOPI)

• Duration: 2 years

• Mode of Onset: Acute

• Course: Episodic

Body of HOPI:

Ms. B, a 27-year-old marketing professional, began experiencing symptoms of panic attacks

two years ago during a particularly stressful period at work. She had recently taken on a new

role that required her to meet tight deadlines and present ideas in front of senior management.

Her first panic attack occurred during an important meeting, where she suddenly felt her heart

racing, had difficulty breathing, and became dizzy. She initially thought she was having a

medical emergency and had to leave the room abruptly. This incident left her feeling

embarrassed and anxious about the possibility of another episode, especially in similar

professional settings.

Over time, the fear of having another panic attack became overwhelming, leading her to

avoid presentations and meetings altogether. Even outside of work, she began to feel uneasy

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in crowded places, public transport, and social gatherings, as she worried she might have

another attack with no way to escape. The panic attacks occur unpredictably, sometimes even

when she is at home, making her feel as though she has no control over them. During an

attack, she experiences intense fear, sweating, trembling, a racing heartbeat, and shortness of

breath, which makes her feel like she is suffocating. These symptoms typically last for

several minutes and leave her feeling exhausted and drained.

Initially, Ms. B tried managing her symptoms on her own by avoiding stressful situations and

practicing deep breathing exercises. However, the attacks continued, and she began to notice

that even when she was not experiencing an attack, she constantly worried about when the

next one would occur. This persistent anxiety made it difficult for her to focus on her work

and affected her overall confidence. She started avoiding traveling alone, preferred working

from home when possible, and declined invitations to events where she might feel trapped or

overwhelmed.

Despite being social and outgoing in the past, Ms. B now hesitates to engage in conversations

about her struggles, as she feels others may not understand. Her family is supportive but

unaware of the severity of her condition. She has not sought treatment before because she

believed she could manage it on her own. However, recently, the episodes have become more

frequent and intense, significantly impacting both her professional and personal life.

Realizing that her condition was worsening, she decided to seek help.

• Precipitating Factors: Work-related stress and a history of anxiety.

NEGATIVE HISTORY

• No history of substance abuse or medical illness.

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MEDICAL HISTORY

• Illness: None.

• Operation: None.

• Accidents: None.

• Surgical Problem: None.

PAST PSYCHIATRIC HISTORY

• Dates: Not applicable.

• Duration: Not applicable.

• Symptoms: Not applicable.

• Diagnosis: Not applicable.

• Treatment: Not applicable.

FAMILY HISTORY

Ms. B comes from a nuclear family of four members, including her parents and an older

brother. Her father, aged 58, is a retired bank employee, and her mother, aged 55, is a

homemaker. Her older brother, aged 30, is employed as an engineer and lives separately with

his family.

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There is no history of psychiatric illness or significant medical conditions in the family. Both

parents are in good health and have been supportive of Ms. B, though they are unaware of the

severity of her current struggles with panic attacks. The family environment is described as

warm and nurturing, with open communication. However, Ms. B has not shared the extent of

her anxiety and avoidance behaviors with her family, as she fears they may not fully

understand her condition.

PERSONAL HISTORY

• Date of Birth: 25/11/1996

• Place of Birth: Chennai, Tamil Nadu

• Birth History: Full-term normal delivery.

• Delivery Type: Normal

• Birth Cry: Normal

• Mother’s Condition During Pregnancy: No complications.

• Postnatal History: Breastfed, no significant issues.

• Physical Health During Infancy: Healthy.

• Delay in Milestone Development: None.

o Motor: Achieved normally.

o Adaptive: Achieved normally.

o Speech: Achieved normally.

o Social: Achieved normally.

• Neurotic Symptoms in Childhood: None reported.

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• Night Terrors: None reported.

• Behavior Problems During Childhood: None reported.

• Habits During Childhood: Regular sleep and eating patterns.

• Childhood Health: No significant illnesses.

• Home Atmosphere During Childhood: Satisfactory.

• Emotional Problems in Adolescence: None reported.

• Home Atmosphere During Adolescence: Satisfactory.

• Parental Lack: Not elicited.

• Anomalous Family Situation: Not elicited.

EDUCATIONAL HISTORY

• Age of Beginning School: 5 years

• Special Abilities/Disabilities: None.

• Academic Performance: Excellent.

• Number of Friends: Many friends.

• Relationship with Friends: Good.

• Co-curricular Activities: Active in debates and cultural events.

• Hobbies and Interests: Traveling and exploring new cultures.

OCCUPATIONAL HISTORY

• Age of Starting Work: 24 years

• Work Record: Satisfactory.

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• Past Job: Marketing executive at a mid-sized firm.

• Present Job: Marketing professional at a reputed company.

• Job Satisfaction: Previously high, but currently affected by anxiety.

MENSTRUAL HISTORY

• Age of Menarche: 13 years

• Regularity/Duration: Regular, 28-day cycle.

• Amount of Physical Pain: Mild discomfort.

• Emotional Problems if Any: None reported.

SEXUAL INCLINATIONS AND PRACTICE

• Sexual Information Acquired Through: Not elicited.

• Masturbation/Sexual Fantasies: Not elicited.

• Homosexuality/Heterosexuality: Heterosexual.

• Sexual Problems if Any: Not elicited.

MARITAL HISTORY

• Spouse Age: Not applicable.

• Duration of Marriage: Not applicable.

• Occupation: Not applicable.

• Personality: Not applicable.

• Compatibility: Not applicable.

PREMORBID PERSONALITY

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• Social Relations:

o Family: Close but currently hesitant to share her struggles.

o Friends: Many friends, though she has become more withdrawn.

o Relatives: Cordial.

o Societies: Active in professional networks.

o Workmates: Friendly but avoids socializing due to anxiety.

• Intellectual Activities:

o Hobbies: Traveling and reading.

o Interests: Marketing and cultural exploration.

o Memory: Good.

o Observation: Keen.

o Judgement: Sound.

• Mood of Client:

o Generally stable but prone to anxiety.

• Character:

o Responsible and ambitious.

• Fantasy Life: Minimal daydreaming.

• Habits:

o Eating: Regular.

o Alcohol Consumption: None.

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o Self-Medication: None.

o Tobacco Consumption: None.

o Sleeping Patterns: Generally regular, but disrupted during stressful periods.

o Excretory Functions: Normal.

o Use of Other Recreational Drugs: None.

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE AND BEHAVIOUR:

• Appearance: Looking one’s age.

• Level of Grooming: Normal.

• Level of Cleanliness: Adequate.

• Level of Consciousness: Fully conscious and alert.

• Mode of Entry: Came willingly.

• Cooperativeness: Normal.

• Eye-to-Eye Contact: Maintained.

• Psychomotor Activity: Normal.

• Empathy: Spontaneous.

• Quality of Rapport: Good.

• Gesturing: Normal.

• Posturing: Normal posture.

• Other Movements: None reported.

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• Other Catatonic Phenomena: None reported.

SPEECH:

• Initiation: Spontaneous.

• Reaction Time: Normal.

• Speed: Normal.

• Output: Normal.

• Pressure of Speech: Absent.

• Volume: Normal.

• Tone: Normal variation.

• Manner: Normal.

• Relevance: Fully relevant.

• Stream: Normal.

• Coherence: Fully coherent.

• Others: None reported.

Sample of Speech:

Question: "Can you tell me more about how your panic attacks started?"

Response: "It started about two years ago when I was at work. I had just taken on a new role,

and there was a lot of pressure to meet deadlines and present ideas to senior management.

During one important meeting, I suddenly felt my heart racing, and I couldn’t breathe

properly. I thought I was having a heart attack or something. I had to leave the room, and

after that, I started worrying it would happen again."

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THOUGHT:

• Tempo: Normal.

• Form: Adequate.

• Obsession: None reported.

• Compulsion: None reported.

• Thought Alienation Phenomena: None reported.

• Thought Contents:

o Ideas: Fear of having another panic attack, helplessness, and worthlessness

due to inability to control symptoms.

o Overvalued Ideas: Fear of situations that might trigger panic attacks.

o Delusions: None reported.

o Suicidal Ideas: Denies any suicidal ideation.

o Other Thoughts: Worry about future panic attacks and their impact on her

life.

MOOD:

• Subjective: Reports feeling anxious, fearful, and helpless.

• Objective: Appears anxious but cooperative. Mood is reactive and congruent with her

reported symptoms.

Impression: mood is congruent with affect

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PERCEPTION:

• Hallucinations: None reported.

• Illusions: None reported.

• Depersonalization/Derealization: None reported.

• Other Perceptual Abnormalities: None reported.

Impression: perception intact

COGNITIVE FUNCTIONS:

• Attention: Normally aroused.

• Digit Forward: 6/6.

• Digit Backward: 5/6.

• Concentration: Normally sustained.

o 100 – 7Test: Completed accurately (93, 86, 79, 72, 65).

o 40 – 3 Test: Completed accurately (37, 34, 31, 28, 25).

o 20 – 1 Test: Completed accurately (19, 18, 17, 16, 15).

o Names of months (backwards): Performed correctly.

o Names of weekdays (backwards): Performed correctly.

Impression: attention or concentration intact

ORIENTATION:

• Time: Fully oriented (knows the date, day, month, and year).

• Place: Fully oriented (knows the kind of place, area, and city).

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• Person: Fully oriented (knows self, close associates, and hospital staff).

Impression: orientation to time, place, and person intact

MEMORY:

• Immediate: Normal (digit forward and backward tests)

• Recent: Normal The patient was able to recall his last meal and the fact that he was

brought to the hospital by his brother.

• Remote: Normal Intact. The patient was able to recall significant personal and

impersonal events.

Impression: memory intact

INTELLIGENCE:

• Comprehension: Normal

• Simple commands: The patient was able to follow simple commands (e.g., "Close

your eyes," "Raise your hand").

• Complex commands: The patient had difficulty following complex commands (e.g.,

"Take this paper in your left hand, fold it in half, and place it on the table").

• Vocabulary: Normal

• Common objects: The patient was able to name common objects (e.g., pen, chair,

book) without difficulty.

• Uncommon objects: The patient struggled to name uncommon objects (e.g.,

stethoscope, microscope).

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• Parts of objects: The patient was able to identify parts of objects (e.g., "What is the

part of a chair you sit on?" Answer: "Seat").

• Arithmetic Ability: Normal

• Mental arithmetic: The patient was able to perform simple calculations (e.g., 5 + 7 =

12) but struggled with more complex problems (e.g., 23 – 8 = 15).

• General Fund of Information: Normal Name of the Prime Minister: The patient

was able to name the current Prime Minister correctly (e.g., "Narendra Modi").

• 5 rivers, cities, or states: The patient was able to name 5 rivers (e.g., Ganga, Yamuna,

Brahmaputra, Godavari, Krishna) and 5 cities (e.g., Delhi, Mumbai, Chennai,

Kolkata, Kochi).

• Capitals of countries: The patient was able to name the capitals of a few countries

(e.g., India – New Delhi, USA – Washington D.C., UK – London).

• Current events (Major): The patient was able to recall some major current events

(e.g., "There was a flood in Kerala last month").

Impression: Intelligence average

ABSTRACTION:

Interpretation of Proverbs:

"People who live in glass houses shouldn’t throw stones."

Patient’s Interpretation: "If you live in a glass house, stones will break it."

"A stitch in time saves nine."

Patient’s Interpretation: "If you fix something right away, it won’t get worse later."

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Similarities Between Paired Objects:

"How are an apple and an orange alike?"

Patient’s Response: "Both are fruits."

Dissimilarities Between Paired Objects:

"How are a car and a bicycle different?"

Patient’s Response: "A car has an engine, and a bicycle doesn’t."

Impression: Abstraction intact

JUDGMENT:

• Personal: Intact (plans for future and recognizes personal capability).

• Social: Intact (understands social and cultural norms).

• Test: Intact

• "What would you do if you found a stamped, addressed envelope on the street?"), the

patient responded, "I would mail it to the address." (Intact judgment.)

Impression: Judgment is intact.

INSIGHT:

• Awareness of Abnormal Behavior/Experience: Yes.

• Attribution to Physical Causes: No.

• Recognition of Personal Responsibility: Yes.

• Willingness to Take Treatment: Yes.

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• Grade: 5 (Intellectual insight: Aware of being ill and that symptoms are due to

irrational thoughts, but struggles to apply this to current experiences).

• Motivation for Treatment: High, as she recognizes the impact of her condition on

her life.

DIAGNOSTIC FORMULATION:

Diagnostic Scheme:

• Major Diagnosis: Panic Disorder (ICD-10 F41.0).

• Differential Diagnosis:

1. Generalized Anxiety Disorder (GAD).

2. Social Anxiety Disorder (Social Phobia).

3. Agoraphobia without panic disorder.

• Associated Diagnoses: None reported.

• Reasons for Entertaining the Diagnoses:

o Recurrent panic attacks with physical symptoms (palpitations, sweating,

trembling, dizziness).

o Fear of having another panic attack leading to avoidance behavior.

o No history of substance abuse or medical illness that could explain symptoms.

o Symptoms are not better explained by another mental disorder (e.g., GAD or

social phobia).

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PSYCHOPATHOLOGY:

• Core Symptoms: Recurrent panic attacks, anticipatory anxiety, and avoidance

behavior.

• Psychological Factors: Work-related stress, fear of losing control, and helplessness.

• Impact on Functioning: Significant impairment in professional and personal life due

to avoidance and anxiety.

PSYCHOTHERAPY AND MANAGEMENT:

Psychotherapy:

• Cognitive Behavioral Therapy (CBT): Focus on identifying and challenging

irrational thoughts related to panic attacks. Exposure therapy to gradually reduce

avoidance behavior.

• Relaxation Techniques: Deep breathing, progressive muscle relaxation, and

mindfulness to manage physical symptoms of anxiety.

• Psychoeducation: Educate Ms. B about panic disorder, its symptoms, and the role of

avoidance in maintaining the condition.

Pharmacotherapy:

• Selective Serotonin Reuptake Inhibitors (SSRIs): First-line treatment for panic

disorder (e.g., sertraline or escitalopram).

• Benzodiazepines: Short-term use for acute symptom relief (e.g., clonazepam), but

with caution due to risk of dependence.

Lifestyle Modifications:

• Stress Management: Encourage regular exercise, balanced diet, and adequate sleep.
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• Work-Life Balance: Address work-related stress through time management and

boundary setting.

Follow-Up:

• Regular monitoring of symptoms and treatment response.

• Adjust treatment plan as needed based on progress.

PROGNOSIS:

• Good Prognostic Factors: High motivation for treatment, supportive family, and no

comorbid psychiatric or medical conditions.

• Potential Challenges: Chronicity of symptoms (2 years) and avoidance behavior may

require longer-term intervention.

CONCLUSION:

Ms. B presents with symptoms consistent with Panic Disorder, characterized by recurrent

panic attacks, anticipatory anxiety, and avoidance behavior. A combination of psychotherapy

(CBT) and pharmacotherapy (SSRIs) is recommended, along with lifestyle modifications to

address stress and improve overall functioning. With appropriate treatment, her prognosis is

favorable.

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CASE HISTORY 5

SOCIO-DEMOGRAPHIC DATA

Name: Mr. C

Age: 38

Date of Birth: 18/03/1985

Sex: Male

Education: Master’s degree in Engineering

Occupation: Engineer

Annual Income: Not elicited

Marital Status: Married

Residence: Urban, lives with spouse and one child

Mother Tongue: Marathi

Religion: Hindu

REFERRAL DETAILS

Referral Source: Self-referred after struggling with intrusive thoughts and compulsive

behaviors.

INFORMANT DETAILS

Name: Mrs. C (Spouse)

Relationship with Client: Spouse

Acquaintance: Long-term

Adequacy: Adequate

Reliability: Reliable

PRESENTING COMPLAINTS

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According to Informant:

Spends excessive time cleaning and organizing the house.

Repeatedly checks locks and appliances.

Appears anxious and distressed when unable to perform these behaviors.

According to Client:

Experiences intrusive thoughts about contamination and harm.

Feels compelled to perform rituals like washing hands and checking locks to reduce anxiety.

HISTORY OF PRESENTING ILLNESS (HOPI)

Duration: 7 years

Mode of Onset: Insidious

Course: Continuous

Mr. C, a 38-year-old male with a master’s degree in Engineering, presented with a 7-year

history of intrusive thoughts and compulsive behaviors. The symptoms began shortly after

the birth of his first child, when he became overly concerned about cleanliness and safety.

Initially, he experienced mild intrusive thoughts about germs and contamination, which he

dismissed as normal parental worries. However, over time, these thoughts became more

frequent and distressing, leading to the development of compulsive behaviors.

Mr. C reported spending several hours a day performing rituals to alleviate the anxiety caused

by his intrusive thoughts. These rituals included excessive hand washing, cleaning, and

checking locks. He described feeling compelled to wash his hands repeatedly, often up to 20

times a day, to remove perceived contamination. If he tried to resist the urge, he experienced

overwhelming anxiety and a sense of impending doom. Similarly, he felt compelled to check

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locks and appliances multiple times before leaving the house or going to bed, fearing that his

negligence might harm his family.

The rituals significantly interfered with Mr. C’s daily life and work. He often arrived late to

work due to the time spent performing his rituals and struggled to concentrate on tasks, as his

mind was preoccupied with thoughts of contamination and harm. His spouse reported that he

spent hours cleaning the house, often rearranging items to ensure they were “perfectly

aligned.” This behavior led to frequent arguments, as his spouse felt frustrated by his inability

to stop the rituals.

Mr. C described feeling intense distress when unable to perform his rituals. He reported that

the anxiety would build up until he felt compelled to give in, even if it meant disrupting his

daily routine. For example, he would often leave social gatherings early to return home and

check the locks or wash his hands. This avoidance behavior further isolated him from friends

and family, as he began to decline invitations to events to avoid the discomfort of being away

from home.

Despite recognizing that his thoughts and behaviors were excessive and irrational, Mr. C felt

unable to control them. He described feeling trapped in a cycle of anxiety and compulsion,

stating, “I know it doesn’t make sense, but I can’t stop myself.” The constant preoccupation

with cleanliness and safety left him feeling exhausted and overwhelmed, further impacting

his mood and quality of life.

Precipitating Factors: Stress related to increased parental responsibilities and perfectionistic

tendencies.

NEGATIVE HISTORY

No history of substance abuse.

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No history of medical or neurological illnesses.

MEDICAL HISTORY

No significant medical or surgical history.

PAST PSYCHIATRIC HISTORY

No prior psychiatric treatment or hospitalization.

FAMILY HISTORY

Mr. C was raised in a middle-class nuclear family. There is no reported history of psychiatric

illness in his family. His parents and younger brother are in good health. His spouse has

expressed concern about his worsening condition over the years.

PERSONAL HISTORY

Date of Birth: 18/03/1985

Place of Birth: Not elicited

Birth History: Full-term normal delivery

Delivery Type: Normal

Birth Cry: Present

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Mother’s Condition During Pregnancy: No complications reported

Postnatal History: Normal

Physical Health During Infancy: Normal

Developmental Milestones: Achieved on time

Neurotic Symptoms in Childhood: Not elicited

Night Terrors: Not elicited

Behavioral Problems During Childhood: Not reported

Home Atmosphere During Childhood: Satisfactory

Emotional Problems in Adolescence: Not reported

Parental Lack: Not elicited

Anomalous Family Situations: None reported

EDUCATIONAL HISTORY

Age of Beginning School: Not elicited

Academic Performance: Excellent

Special Abilities/Disabilities: None reported

Number of Friends: Many

Relationship with Friends: Good

Co-curricular Activities: Active in sports

Hobbies and Interests: Engineering and technology

OCCUPATIONAL HISTORY

Age of Starting Work: Not elicited

Work Record: Consistent employment but impacted by compulsions

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Past Job: Engineering roles

Present Job: Engineer with work disruptions due to OCD

Job Satisfaction: Previously high, now impacted by compulsions

MARITAL HISTORY

Spouse’s Age: Not elicited

Duration of Marriage: Not elicited

Occupation of Spouse: Not elicited

Personality: Supportive but distressed

Compatibility: Initially good, currently strained due to compulsive behaviors

PREMORBID PERSONALITY

Social Relations: Extroverted, many friends

Intellectual Activities: Interested in engineering and technology

Mood: Generally stable but prone to anxiety

Character: Responsible and hardworking

Fantasy Life: Minimal daydreaming

Habits: Regular sleep and eating patterns; compulsions interfere with routine

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Mental Status Examination

General Appearance and Behavior

• Appearance: Looking one’s age.

• Level of Grooming: Overtly clean (excessive attention to cleanliness).

• Level of Cleanliness: Overtly clean.

• Level of Consciousness: Fully conscious and alert.

• Mode of Entry: Came willingly.

• Cooperativeness: Normal.

• Eye-to-Eye Contact: Maintained but hesitant.

• Psychomotor Activity: Increased restlessness (fidgety when discussing rituals).

• Empathy: Spontaneous.

• Quality of Rapport: Good.

• Gesturing: Normal.

• Posturing: Normal posture.

• Other Movements: None (no mannerisms, stereotypes, tremors, EPS, AIMS, or

perseveration).

• Other Catatonic Phenomena: None (no automatic obedience, negativism, waxy

flexibility, echopraxia, or echolalia).

• Impression: Intact (no significant abnormalities in general behavior).

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Speech

• Initiation: Speaks when spoken to.

• Reaction Time: Normal.

• Speed: Normal.

• Output: Normal.

• Pressure of Speech: Absent.

• Volume: Normal.

• Tone: Monotonous.

• Manner: Highly formal.

• Relevance: Fully relevant.

• Stream: Normal.

• Coherence: Fully coherent.

• Others: None (no rhyming, punning, echolalia, perseveration, or neologism).

• Sample of Speech: Responds formally and precisely, e.g., “I have to wash my hands

multiple times to feel clean… otherwise, I feel contaminated.”

• Impression: Intact (speech is coherent and relevant, though overly formal).

Thought

• Tempo: Normal.

• Form: Adequate.

• Obsession:

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o Thought: Intrusive thoughts about contamination and harm.

o Doubt: Fear of causing harm to his family due to negligence.

o Impulse: Urge to wash hands or check locks repeatedly.

o Image: Vivid mental images of germs and contamination.

o Rumination: Persistent thoughts about cleanliness and safety.

• Compulsion:

o Yielding: Performs rituals like hand washing and checking locks.

o Controlling: Tries to resist but feels overwhelming anxiety.

o Cognitive Compulsion: Mental rituals like counting or repeating phrases.

• Thought Alienation Phenomena: None (no thought insertion, withdrawal, or

broadcast).

• Thought Commentary: None.

• Thought Contents:

o Idea: Contamination, harm, and responsibility.

o Overvalued Idea: Belief that his rituals prevent harm to his family.

o Delusion: None.

o Example: “If I don’t wash my hands 10 times, my child might get sick.”

• Impression: Not Intact (presence of intrusive thoughts, compulsions, and overvalued

ideas).

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Mood

• Subjective: “I feel anxious and overwhelmed by my thoughts.”

• Objective: Anxious and apprehensive.

• Predominant Mood State: Anxious.

• Other Major Moods: None.

• Range: Restricted.

• Reactivity: Reactive.

• Quality of Mood: Tense and worried.

• Communicability: Good.

• Lability: None.

• Appropriateness: Appropriate to thought content.

• Congruence: Mood congruent.

• Emotional Expression: Normal.

• Impression: Intact (mood is congruent with affect and thought content).

Perception

• Hallucination: None.

• Illusion: None.

• Depersonalization: None.

• Déjà Vu Phenomena: None.

• Somatic Passivity: None.

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• Special: None (no made acts).

• Impression: Intact (no perceptual abnormalities).

Cognitive Functions

• Attention: Normally aroused.

• Digit Forward: 5/5.

• Digit Backward: 4/5.

• Concentration: Normally sustained.

• 100-7 Test: 93, 86, 79, 72, 65 (completed without difficulty).

• 40-3 Test: 37, 34, 31, 28, 25 (completed without difficulty).

• 20-1 Test: 19, 18, 17, 16, 15 (completed without difficulty).

• Months Backwards: Completed without difficulty.

• Weekdays Backwards: Completed without difficulty.

• Impression: Intact (cognitive functions are preserved).

Orientation

• Time: Approximate time (knows day, date, month, and year).

• Place: Kind of place (knows he is in a clinic).

• Person: Self and close associates (recognizes himself and family members).

• Impression: Intact (oriented to time, place, and person).

Memory

• Immediate: 3/3 objects recalled immediately.

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• Recent: Recalls last meal and visitors.

• Verbal Recall:

o After 5 minutes: 3/3 objects.

o After 10 minutes: 3/3 objects.

• Visual Recall: 3/3 objects recalled.

• Remote: Recalls personal and impersonal events accurately.

• Impression: Intact (memory is preserved).

Intelligence

• Comprehension: Understands simple and complex commands.

• Vocabulary: Good (can name common and uncommon objects).

• Arithmetic Ability: Adequate (can perform mental arithmetic).

• General Fund of Information:

o Literate: Knows the name of the Prime Minister, 5 rivers, cities, states, and

capitals of countries.

o Current Events: Aware of major current events.

• Impression: Intact (intelligence is average).

Abstraction

• Interpretation of Proverbs: Concrete.

o “A stitch in time saves nine” interpreted as “Sewing saves clothes.”

• Similarities Between Paired Objects: Concrete.

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o “Apple and orange” interpreted as “Both are fruits.”

• Dissimilarities Between Paired Objects: Concrete.

o “Book and TV” interpreted as “One is for reading, the other is for watching.”

• Impression: Not Intact (abstract thinking is concrete).

Judgment

• Personal: Impaired (unable to stop rituals despite recognizing their irrationality).

• Social: Intact (understands social norms).

• Test: Impaired (predicts harm if rituals are not performed).

• Impression: Not Intact (impaired judgment due to compulsions).

Insight

• Awareness of Abnormal Behavioral/Experience: Yes.

• Attribution to Physical Causes: No.

• Recognition of Personal Responsibility: Yes.

• Willingness to Take Treatment: Yes.

• Grade: 4 (Awareness of being sick, due to something unknown in self).

• Motivation/Willingness for Treatment: Motivated but feels overwhelmed by

symptoms.

• Impression: Partially Intact (partial insight into the illness).

DIAGNOSTIC FORMULATION

Major Diagnosis: Obsessive-Compulsive Disorder (OCD).

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Differential Diagnosis: Generalized Anxiety Disorder, Obsessive-Compulsive Personality

Disorder.

Associated Diagnoses: None.

PSYCHOPATHOLOGY

Mr. C exhibits classic symptoms of Obsessive-Compulsive Disorder (OCD), characterized by

persistent intrusive thoughts (obsessions) related to contamination and harm, leading to

compulsive behaviors such as excessive hand washing and repetitive checking of locks to

reduce anxiety. His insight is partial, as he recognizes the irrationality of his behaviors but

struggles to control them, resulting in significant functional impairment in both personal and

professional life. His anxious mood, heightened distress when rituals are interrupted, and

avoidance behaviors further reinforce the compulsions. Additionally, his rigid cognitive style

and perfectionistic tendencies suggest a possible obsessive-compulsive personality trait,

though the compulsions are distressing rather than ego-syntonic. The concrete thinking and

impaired judgment observed in his mental status examination reflect his difficulty in abstract

reasoning and resisting compulsive urges. Overall, his symptoms have a chronic and

continuous course, worsening over the years and significantly affecting his quality of life.

PSYCHOTHERAPY AND MANAGEMENT

Medications: Selective Serotonin Reuptake Inhibitors (SSRIs) (e.g., Fluoxetine).

Therapy: Cognitive Behavioral Therapy (CBT) with Exposure and Response Prevention

(ERP).

Social Support: Family counseling and psychoeducation.

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CASE HISTORY 6

SOCIO-DEMOGRAPHIC DATA

• Name: Ms. F

• Age: 32

• Date of Birth: 15/04/1991

• Sex: Female

• Education: Master’s degree in Psychology

• Occupation: Unemployed (due to medical condition)

• Annual Income: Not applicable

• Marital Status: Unmarried

• Residence: Urban, lives with parents

• Mother Tongue: Tamil

• Religion: Hindu

REFERRAL DETAILS

• Referral Source: Referred by her neurologist due to recurrent seizures.

• Informant Details:

o Name: Mrs. F (mother)

o Relationship with Client: Mother

o Acquaintance: Adequate

o Adequacy: Adequate

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o Reliability: Reliable

PRESENTING COMPLAINTS

• According to Informant:

o Experiences recurrent seizures characterized by loss of consciousness and

convulsions.

o Appears confused and disoriented after seizures.

o Reports feeling anxious and depressed due to the condition.

• According to Client:

o Admits to experiencing recurrent seizures but feels unable to control them.

o Reports feeling anxious and depressed due to the impact of seizures on her

life.

HISTORY OF PRESENTING ILLNESS (HOPI)

• Duration: 5 years

• Mode of Onset: Acute

• Course: Episodic

Body of HOPI:

Ms. F, a 32-year-old female with a Master’s degree in Psychology, has been experiencing

recurrent seizures for the past five years. The onset of symptoms was acute, following a head

injury sustained in a car accident. Prior to the accident, she had no history of neurological or

psychiatric concerns. The initial episodes were mild, characterized by brief moments of

disorientation and occasional muscle stiffness, which were dismissed as temporary effects of

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the injury. However, over the months following the accident, she began experiencing full-

blown seizures marked by sudden loss of consciousness, convulsions, and postictal

confusion.

The course of her condition has been episodic, with seizures occurring unpredictably. There

are no clear identifiable triggers, though she and her family have observed that episodes tend

to occur more frequently during periods of emotional distress or sleep deprivation. She

experiences postictal confusion and fatigue, often requiring several hours to fully recover.

The unpredictability of these episodes has created significant distress, as she feels a loss of

control over her own body.

She was initially prescribed antiepileptic medication, which provided partial relief. However,

she continues to experience breakthrough seizures, leading to frequent adjustments in her

medication regimen. Despite adherence to treatment, the persistent nature of her condition

has left her feeling frustrated and hopeless. She has sought multiple medical opinions, with

no definitive improvement in seizure control.

The condition has had a significant impact on her psychological well-being. She reports

experiencing persistent anxiety and low mood, particularly due to concerns about seizures

occurring in public or professional settings. She has become increasingly socially withdrawn,

avoiding gatherings and limiting interactions even with close friends. Professionally, she has

faced challenges in maintaining employment, as prospective employers hesitate to

accommodate her condition. This has led to a decline in self-esteem and feelings of

worthlessness, as she struggles with a perceived loss of independence.

Her mother, who serves as the primary informant, reports that Ms. F has become more

irritable and emotionally fragile over time. She expresses frustration over her condition but

refrains from openly discussing her emotions with family members. Despite a supportive

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home environment, she often isolates herself, preferring to stay in her room for extended

periods. Her mother also notes a change in her sleep patterns, with increased restlessness and

difficulty falling asleep.

In terms of coping mechanisms, Ms. F initially tried to stay engaged in activities like reading

and writing, which she enjoyed. However, over time, she has lost interest in these hobbies.

She often feels helpless and dependent on her family, which adds to her frustration. Since she

is unable to work due to her seizures, she feels like she is a burden on her parents. While she

has experienced occasional thoughts of hopelessness, she does not have any active suicidal

intent or plans.

Stress seems to make her seizures worse. She notices that during times of high emotional

distress, such as arguments at home or worries about her future, her seizure episodes become

more frequent. She also feels pressured by social expectations, especially as an unmarried

woman in her 30s. She worries about her career and personal life, particularly how her

condition may affect her chances of marriage or finding a stable job. These concerns have

further contributed to her anxiety and low mood.

Overall, despite taking medications, her seizures continue to affect her daily life, confidence,

and independence. She is hesitant about seeking psychological counseling, as she is unsure if

it will help. However, she agrees that she needs emotional support and is open to discussing

ways to better manage her stress and anxiety. There is a need for a structured psychological

intervention to help her cope with her condition and improve her overall well-being.

• Precipitating Factors: Head injury and stress.

NEGATIVE HISTORY

• No history of substance abuse or other medical illness.

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MEDICAL HISTORY

• Illness: Epilepsy (diagnosed post head injury).

• Operation: None.

• Accidents: Head injury sustained in a car accident.

• Surgical Problem: None.

PAST PSYCHIATRIC HISTORY

• Dates: Not applicable.

• Duration: Not applicable.

• Symptoms: Not applicable.

• Diagnosis: Not applicable.

• Treatment: Not applicable.

FAMILY HISTORY

Ms. F comes from a nuclear family of four members, including her parents and an older

brother. The family resides in an urban area and belongs to the middle socioeconomic class.

Her father, aged 60, is a retired government employee, and her mother, aged 58, is a

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homemaker. Her older brother, aged 35, is employed as a software engineer and lives

separately with his family.

There is no history of psychiatric illness or significant medical conditions in the family. Both

parents are in good health and have been supportive of Ms. F throughout her struggles with

epilepsy. However, they express concern about her emotional well-being and future

prospects, particularly regarding her career and marriage. The family environment is

described as warm and nurturing, though Ms. F has become increasingly withdrawn and

irritable over the years.

PERSONAL HISTORY

• Date of Birth: 15/04/1991

• Place of Birth: Chennai, Tamil Nadu

• Birth History: Full-term normal delivery.

• Delivery Type: Normal

• Birth Cry: Normal

• Mother’s Condition During Pregnancy: No complications.

• Postnatal History: Breastfed, no significant issues.

• Physical Health During Infancy: Healthy.

• Delay in Milestone Development: None.

o Motor: Achieved normally.

o Adaptive: Achieved normally.

o Speech: Achieved normally.

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o Social: Achieved normally.

• Neurotic Symptoms in Childhood: None reported.

• Night Terrors: None reported.

• Behavior Problems During Childhood: None reported.

• Habits During Childhood: Regular sleep and eating patterns.

• Childhood Health: No significant illnesses.

• Home Atmosphere During Childhood: Satisfactory.

• Emotional Problems in Adolescence: None reported.

• Home Atmosphere During Adolescence: Satisfactory.

• Parental Lack: Not elicited.

• Anomalous Family Situation: Not elicited.

EDUCATIONAL HISTORY

• Age of Beginning School: 5 years

• Special Abilities/Disabilities: None.

• Academic Performance: Excellent.

• Number of Friends: Few close friends.

• Relationship with Friends: Good.

• Co-curricular Activities: Active in debates and literature clubs.

• Hobbies and Interests: Reading and writing.

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OCCUPATIONAL HISTORY

• Age of Starting Work: Not applicable (unemployed due to medical condition).

• Work Record: Not applicable.

• Past Job: Not applicable.

• Present Job: Unemployed.

• Job Satisfaction: Not applicable.

MENSTRUAL HISTORY

• Age of Menarche: 13 years

• Regularity/Duration: Regular, 28-day cycle.

• Amount of Physical Pain: Mild discomfort.

• Emotional Problems if Any: None reported.

SEXUAL INCLINATIONS AND PRACTICE

• Sexual Information Acquired Through: Not elicited.

• Masturbation/Sexual Fantasies: Not elicited.

• Homosexuality/Heterosexuality: Heterosexual.

• Sexual Problems if Any: Not elicited.

MARITAL HISTORY

• Spouse Age: Not applicable.

• Duration of Marriage: Not applicable.

• Occupation: Not applicable.

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• Personality: Not applicable.

• Compatibility: Not applicable.

PREMORBID PERSONALITY

• Social Relations:

o Family: Close but currently withdrawn.

o Friends: Few close friends.

o Relatives: Cordial.

o Societies: Not applicable.

o Workmates: Not applicable.

• Intellectual Activities:

o Hobbies: Reading and writing.

o Interests: Psychology and literature.

o Memory: Good.

o Observation: Keen.

o Judgement: Sound.

• Mood of Client:

o Generally stable but prone to anxiety.

• Character:

o Responsible and perfectionistic.

• Fantasy Life: Minimal daydreaming.

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• Habits:

o Eating: Regular.

o Alcohol Consumption: None.

o Self-Medication: None.

o Tobacco Consumption: None.

o Sleeping Patterns: Restless, difficulty falling asleep.

o Excretory Functions: Normal.

o Use of Other Recreational Drugs: None.

MENTAL STATUS EXAMINATION

General Appearance and Behavior:

• Appearance: Looking one’s age.

• Level of Grooming: Normal.

• Level of Cleanliness: Adequate.

• Level of Consciousness: Fully conscious and alert.

• Mode of Entry: Came willingly.

• Cooperativeness: Normal.

• Eye-to-Eye Contact: Maintained, but occasionally breaks eye contact when

discussing emotional topics.

• Psychomotor Activity: Normal, with occasional restlessness when discussing her

seizures.

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• Empathy: Spontaneous.

• Quality of Rapport: Good.

• Gesturing: Normal.

• Posturing: Normal posture.

• Other Movements: None observed (no tremors, EPS, AIMS, or perseveration).

• Other Catatonic Phenomena: None observed.

Speech:

• Initiation: Speaks when spoken to.

• Reaction Time: Normal.

• Speed: Normal.

• Output: Normal.

• Pressure of Speech: Absent.

• Volume: Normal.

• Tone: Normal variation.

• Manner: Normal.

• Relevance: Fully relevant.

• Stream: Normal.

• Coherence: Fully coherent.

• Others: None observed (no rhyming, punning, echolalia, perseveration, or

neologisms).

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Sample of Speech:

Clinician: "Can you tell me how you’ve been feeling lately?"

Ms. F: "I’ve been feeling very anxious and low. The seizures make me feel like I’ve lost

control over my life. I worry about having them in public or at work, and it’s hard to stay

positive."

Thought:

• Tempo: Normal.

• Form: Adequate (no loosening of associations, formal thought disorder, or muddled

thinking).

• Obsession: None reported.

• Compulsion: None reported.

• Thought Alienation Phenomena: None reported (no thought insertion, withdrawal,

or broadcast).

• Thought Contents:

o Ideas: Worries about her future, career, and marriage prospects.

o Overvalued Ideas: None reported.

o Delusions: None reported.

o Mood-Congruent Themes: Feelings of worthlessness, helplessness, and

hopelessness due to her condition.

o Suicidal Ideas: Denies active suicidal intent or plans but admits to occasional

hopelessness.

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Impression: Thought intact

Mood:

• Subjective: Reports feeling anxious and depressed.

• Objective: Appears sad and anxious, with a restricted range of emotional expression.

• Predominant Mood State: Low mood and anxiety.

• Range: Restricted.

• Reactivity: Reactive to discussion of her condition.

• Quality of Mood: Sad and anxious.

• Communicability: Communicates her emotions clearly.

• Lability: Stable.

• Appropriateness: Mood is congruent with her reported experiences.

• Emotional Expression: Normal, but slightly blunted when discussing her seizures.

Impression: Mood congruent with affect

Perception:

• Hallucinations: None reported.

• Illusions: None reported.

• Depersonalization/Derealization: None reported.

• Déjà Vu Phenomena: None reported.

• Somatic Passivity: None reported.

Impression: perception intact

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Cognitive Functions:

• Attention: Normally aroused.

o Digit Forward: 6/6.

o Digit Backward: 4/6.

• Concentration: Normally sustained.

o 100-7 Test: Completed accurately (93, 86, 79, 72, 65).

o Names of Months Backwards: Completed with minor hesitation.

• Orientation:

o Time: Fully oriented (knows the date, day, month, and year).

o Place: Fully oriented (knows the location and type of place).

o Person: Fully oriented (recognizes self and others).

"Today is Wednesday, October 11th, 2023. I’m at the clinic for my appointment. I came here

with my mother. I know who I am, and I recognize my family members."

Impression: Orientation to time, place, and person intact.

• Memory:

o Immediate: Normal (recalled 3/3 unrelated objects).

o asked to remember three objects: apple, table, and umbrella

o Recent: Normal (recalled details of her last meal and recent events).

o For breakfast, I had toast and tea. My friend Linda visited me yesterday

afternoon.

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o Remote: Normal (recalled personal and impersonal events accurately).

o I remember my graduation day clearly. It was in 2013. I also remember when

India won the Cricket World Cup in 2011.

Impression: Memory intact.

• Intelligence:

o Comprehension: Normal

o Vocabulary: Normal

o Arithmetic Ability: Normal

o General Fund of Information: Normal

Impression: Intelligence average.

• Abstraction: Normal.

o Proverb Interpretation: "Don’t cry over spilled milk" – interpreted "Don’t

cry over spilled milk" means "Don’t dwell on past mistakes."

• Similarities/Dissimilarities: Able to identify similarities and differences between

paired objects

"An apple and an orange are both fruits that you can eat."

• Dissimilarities Between Paired Objects:

"An apple and an orange are both fruits that you can eat."

Impression: Abstraction intact.

• Judgment: Intact.

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o Personal: "If I ran out of my medication, I would call my doctor for a refill."

o Social: "If I saw someone stealing in a store, I would inform the store

manager."

o Test: "If I found a stamped letter on the ground, I would mail it to the address

written on it."

Impression: Judgment intact.

• Insight: Grade 4.

o Awareness of Illness: Acknowledges her seizures and their impact on her life.

o Attribution: Attributes her condition to her head injury and stress.

o Willingness to Take Treatment: Open to psychological counseling and stress

management.

DIAGNOSTIC FORMULATION

Diagnostic Scheme:

• Major Diagnosis:

o Epilepsy with recurrent seizures (ICD-10: G40.9).

o Adjustment Disorder with Mixed Anxiety and Depressed Mood (ICD-10:

F43.23).

• Differential Diagnosis:

o Generalized Anxiety Disorder (ICD-10: F41.1).

o Major Depressive Disorder (ICD-10: F32.9).

• Associated Diagnoses:

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o Psychological distress secondary to chronic medical condition.

o Social withdrawal and occupational dysfunction.

Reasons for Entertaining the Diagnoses:

• Epilepsy: History of recurrent seizures following a head injury, with partial response

to antiepileptic medication.

• Adjustment Disorder: Significant emotional distress, anxiety, and low mood in

response to the impact of her seizures on her personal and professional life.

• Generalized Anxiety Disorder: Persistent anxiety about seizures and their social

consequences, though the anxiety is secondary to her medical condition.

• Major Depressive Disorder: Low mood, feelings of worthlessness, and social

withdrawal, though these symptoms are reactive to her condition.

PSYCHOPATHOLOGY

• Biological Factors: History of head injury leading to epilepsy.

• Psychological Factors: Perfectionistic personality, feelings of helplessness, and low

self-esteem due to her condition.

• Social Factors: Social withdrawal, occupational challenges, and societal pressures as

an unmarried woman in her 30s.

PSYCHOTHERAPY AND MANAGEMENT

Psychotherapy:

1. Cognitive Behavioral Therapy (CBT):

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o Goal: Address negative thought patterns related to her condition (e.g., "I am a

burden," "I have no future").

o Intervention: Cognitive restructuring to challenge maladaptive beliefs and

develop coping strategies for anxiety and depression.

o Verbatim Sample:

▪ Clinician: "You mentioned feeling like a burden on your family. Can

we explore that thought further?"

▪ Ms. F: "Yes, I feel like I can’t contribute because I can’t work or take

care of myself."

▪ Clinician: "What evidence do you have that supports or contradicts

this belief?"

2. Stress Management Techniques:

o Goal: Reduce seizure triggers related to emotional distress.

o Intervention: Teach relaxation techniques (e.g., deep breathing, progressive

muscle relaxation) and mindfulness-based stress reduction.

3. Supportive Therapy:

o Goal: Provide emotional support and validation.

o Intervention: Encourage open expression of emotions and discuss ways to

rebuild social connections.

Pharmacological Management:

• Antiepileptic Medication: Continue current regimen with regular follow-ups to

monitor efficacy and side effects.

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• Antidepressant/Anti-anxiety Medication: Consider SSRIs (e.g., sertraline) to

address depressive and anxious symptoms, if necessary.

Social and Occupational Rehabilitation:

• Goal: Improve quality of life and independence.

• Intervention: Referral to vocational rehabilitation services to explore work

opportunities that accommodate her condition.

Family Psychoeducation:

• Goal: Enhance family support and understanding.

• Intervention: Educate family members about epilepsy and its psychological impact,

and involve them in the treatment process.

PROGNOSIS:

• Guarded: While her seizures may continue, psychological interventions can

significantly improve her emotional well-being and quality of life. With proper

support, she can regain a sense of control and independence.

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CASE HISTORY 7

SOCIO-DEMOGRAPHIC DATA

• Name: Mr. V

• Age: 42 years

• Sex: Male

• Education: High School Graduate

• Occupation: Small Business Owner

• Annual Income: Moderate

• Marital Status: Married

• Residence: Rural

• Mother Tongue: Hindi

• Religion: Hindu

REFERRAL DETAILS

• Referred by: Family due to excessive alcohol consumption, aggression, and neglect

of responsibilities.

• Informant Details:

o Name: Mrs. V (Wife)

o Relationship with Client: Wife

o Acquaintance: Lives with patient

o Adequacy: Good

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o Reliability: High

PRESENTING COMPLAINTS

• Daily alcohol consumption for the past 10 years.

• Increased quantity of alcohol intake – 6 years.

• Neglect of family and work responsibilities – 5 years.

• Aggressive outbursts when confronted – 3 years.

• Withdrawal symptoms on abstinence – 2 years.

HISTORY OF PRESENTING ILLNESS

Mr. V started consuming alcohol socially in his early twenties but gradually increased intake

over the years. Initially, he drank only on weekends, but by his mid-thirties, he began

drinking daily. Over time, the amount of alcohol required to achieve the desired effect

increased, and he found himself drinking in the morning to avoid hangovers.

Six years ago, his wife noticed changes in his behavior. He became irritable, impatient, and

frequently missed work. He justified his drinking by stating that it helped him cope with

financial stress and work pressure. His family members urged him to reduce his intake, but he

insisted he was in control.

Five years ago, his alcohol use led to significant financial strain, as he spent a large portion of

his earnings on alcohol. His business performance declined, and he started borrowing money

from relatives to sustain his drinking habit. He began neglecting household responsibilities,

and his interactions with family became minimal. His wife reported frequent fights due to his

aggressive behavior while intoxicated.

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Three years ago, his aggression intensified, and he had physical altercations with his wife and

children. He displayed impulsive behavior, including reckless spending and making

unrealistic business decisions while under the influence. His wife attempted to seek help from

community elders, but he refused treatment, claiming that drinking was his personal choice.

In the past two years, he has experienced withdrawal symptoms such as tremors, sweating,

and irritability whenever he tried to reduce alcohol intake. He started experiencing memory

blackouts and frequent mood swings. His wife finally convinced him to seek medical help

when he was found unconscious at home after an episode of binge drinking.

NEGATIVE HISTORY

• No history of psychotic symptoms.

• No history of seizures or head trauma.

• No known chronic medical illness.

MEDICAL HISTORY

• No major medical illnesses recorded.

• History of gastritis due to alcohol consumption.

PAST PSYCHIATRIC HISTORY

• No previous psychiatric hospitalizations.

• No prior medication use for psychiatric symptoms.

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FAMILY HISTORY

• Father had a history of alcohol use disorder.

• No history of major psychiatric illnesses in first-degree relatives.

PERSONAL HISTORY

• Date of Birth: 15th June 1981

• Place of Birth: Jaipur, Rajasthan, India

• Birth History: Full-term delivery, normal vaginal delivery, immediate and normal

birth cry.

• Mother’s Condition During Pregnancy: No significant complications.

• Postnatal History: No complications.

• Physical Health During Infancy: Generally healthy.

• Milestones: Achieved normally (motor, adaptive, speech, social).

• Neurotic Symptoms in Childhood: None reported.

• Behavior Problems During Childhood: None reported.

• Habits During Childhood: No significant habits.

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• Childhood Health: Generally healthy.

• Home Atmosphere During Childhood: Satisfactory but with occasional tension due

to father’s alcohol dependence.

• Emotional Problems in Adolescence: Mild rebellious behavior.

• Home Atmosphere During Adolescence: Satisfactory but with some tension.

• Parental Lack: Emotional neglect from father due to his alcohol dependence.

• Anomalous Family Situation: Father’s alcohol dependence created occasional

instability.

EDUCATIONAL HISTORY

• Age of Beginning School: 5 years

• Academic Performance: Average

• Number of Friends: Moderate

• Relationship with Friends: Casual

• Co-curricular Activities: Minimal participation

• Hobbies and Interests: Enjoyed outdoor activities like cricket and cycling.

OCCUPATIONAL HISTORY

• Age of Starting Work: 22 years

• Work Record: Initially satisfactory but declined due to alcohol dependence.

• Present Job: Small business owner (grocery store).

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• Job Satisfaction: Initially satisfied but became dissatisfied due to financial stress and

alcohol dependence.

MENSTRUAL HISTORY

• Not applicable (patient is male).

SEXUAL INCLINATIONS AND PRACTICE

• Sexual Information Acquired Through: Peers and informal sources.

• Masturbation/Sexual Fantasies: Occasional masturbation.

• Homosexuality/Heterosexuality: Heterosexual.

• Sexual Problems: None reported.

MARITAL HISTORY

• Spouse Age: 38 years

• Duration of Marriage: 15 years

• Occupation: Homemaker

• Personality: Supportive but increasingly stressed.

• Compatibility: Initially good but deteriorated due to alcohol use.

PRE-MORBID PERSONALITY

• Social Relations: Close with mother, strained with father.

• Intellectual Activities: Limited interests outside hobbies.

• Mood: Generally stable but with increasing mood fluctuations.

• Character: Initially responsible but became neglectful.

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• Fantasy Life: Occasional daydreaming.

• Habits: Irregular eating and sleeping patterns due to alcohol dependence

MENTAL STATUS EXAMINATION

General Appearance and Behavior

• Appearance: Looking older than his age.

• Level of Grooming: Shabbily dressed.

• Level of Cleanliness: Inadequate.

• Level of Consciousness: Fully conscious and alert.

• Mode of Entry: Persuaded (brought by family members).

• Cooperativeness: Less than normal.

• Eye-to-Eye Contact: Difficult to maintain.

• Psychomotor Activity: Increased restlessness and agitation.

• Empathy: Not established.

• Quality of Rapport: Poor.

• Gesturing: Exaggerated.

• Posturing: Normal posture.

• Other Movements: Tremors (likely due to alcohol withdrawal).

Speech

• Initiation: Spontaneous.

• Reaction Time: Normal.

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• Speed: Rapid (pressured speech).

• Output: Increased.

• Pressure of Speech: Present.

• Volume: Normal.

• Tone: Normal variation.

• Manner: Normal.

• Relevance: Sometimes off-target.

• Stream: Tangential.

• Coherence: Some loosening of associations.

• Sample of Speech:

"I drink because it helps me relax. My family doesn’t understand the stress I’m under.

They think I’m a failure, but I’m not."

Thought

• Tempo: Racy thoughts.

• Form: Loosening of associations.

• Obsession: None observed.

• Compulsion: None observed.

• Thought Alienation Phenomena: None observed.

• Thought Contents:

o Overvalued Ideas: Belief that alcohol is necessary to cope with stress.

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o Hopelessness: Present, related to financial and family issues.

o Guilt: Mild guilt about neglecting family responsibilities.

o Example:

"I know I drink too much, but I can’t stop. It’s the only thing that helps me

forget my problems."

Impression : Thought not intact

Mood

• Subjective: Anxious and irritable.

• Objective: Irritable.

Impression: Mood incongruent with affect

Perception

• Hallucination: None observed.

• Illusion: None observed.

• Depersonalization: None reported.

• Déjà Vu Phenomena: None reported.

Impression: perception intact

Cognitive Functions

• Attention: Normally aroused.

o Digit Forward: 5/5.

o Digit Backward: 4/5.

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• Concentration: Normally sustained but with some difficulty due to distractibility.

o 100 – 7 Test: Completed accurately (93, 86, 79, 72, 65).

o 40 – 3 Test: Completed accurately (37, 34, 31, 28, 25).

o 20 – 1 Test: Completed accurately (19, 18, 17, 16, 15).

o Months Backwards: Completed with some hesitation.

o Weekdays Backwards: Completed with some hesitation.

Impression: Attention and concentration are intact

Orientation

• Time: Fully oriented (knows date, day, month, and year).

• Place: Fully oriented (knows location and type of place).

• Person: Fully oriented (recognizes self and others).

Impression: Orientation to time, place, and person is intact.

Memory

• Immediate Memory: Intact (digit forward and backward tests).

• Recent Memory:

o Recent Happenings: Recalls last meal and being brought to the hospital.

o Verbal Recall: 3/5 objects after 5 minutes, 2/5 after 10 minutes.

o Visual Recall: 2/3 objects after 5 minutes, 1/3 after 10 minutes.

• Remote Memory: Intact (recalls significant personal and impersonal events).

Impression : Immediate and remote memory are intact. Recent memory is mildly impaired.

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Intelligence

• Comprehension: Understands simple commands but struggles with complex ones.

• Vocabulary: Able to name common objects but struggles with uncommon ones.

• Arithmetic Ability: Performs simple calculations but struggles with complex ones.

• General Fund of Information:

o Literate: Completed high school.

o Current Events: Aware of major events (e.g., elections, natural disasters).

Impression: Average intelligence.

Abstraction

• Interpretation of Proverbs: Concrete.

"People who live in glass houses shouldn’t throw stones."

Patient’s Interpretation: "If you live in a glass house, stones will break it."

"A stitch in time saves nine."

Patient’s Interpretation: "If you sew something, it won’t tear."

Similarities Between Paired Objects: Concrete.

"How are an apple and an orange alike?"

Patient’s Response: "Both are fruits."

Dissimilarities Between Paired Objects: Concrete.

"How are a car and a bicycle different?"

Patient’s Response: "A car has an engine, and a bicycle doesn’t."

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Impression: Abstraction is concrete.

Judgment

• Personal: Poor sense of personal capability and worth.

• Social: Impaired sense of socially acceptable behavior.

• Test:

"What would you do if you found a stamped, addressed envelope on the street?"

Patient’s Response: "I would throw it away because it might be a scam."

Impression :Judgment is significantly impaired in personal, social, and test scenarios.

DIAGNOSTIC FORMULATION

• Major Diagnosis: Alcohol Dependence Syndrome (ICD-10: F10.2).

• Differential Diagnosis:

o Generalized Anxiety Disorder (ICD-10: F41.1).

o Major Depressive Disorder (ICD-10: F32.9).

• Associated Diagnoses:

o Adjustment Disorder with Mixed Anxiety and Depressed Mood (ICD-10:

F43.23).

PSYCHOPATHOLOGY

Mr. V, a 42-year-old married male, presented with a history of chronic alcohol use for the

past 15 years, with increased consumption over the last five years. He reports experiencing

strong cravings, inability to control intake, and withdrawal symptoms such as tremors and

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irritability. Despite awareness of the negative impact on his health, work, and family

relationships, he continues drinking, often prioritizing alcohol over responsibilities. His mood

is irritable, with occasional guilt and hopelessness regarding his condition. Cognitive

assessment indicates mild impairment in recent memory. There is no history of hallucinations

or delusions. His insight into his condition is partial, and motivation for change is fluctuating

PSYCHOTHERAPY AND MANAGEMENT

1. Detoxification: Managed withdrawal symptoms with benzodiazepines.

2. Pharmacotherapy:

o Naltrexone: To reduce alcohol cravings.

o SSRIs (e.g., Sertraline): For depressive symptoms.

3. Psychotherapy:

o Cognitive Behavioral Therapy (CBT): To address maladaptive thoughts and

behaviors.

o Motivational Interviewing: To enhance motivation for change.

4. Family Therapy: To improve family dynamics and support.

5. Support Groups: Referral to Alcoholics Anonymous (AA).

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CASE HISTORY 8

SOCIO-DEMOGRAPHIC DATA

• Name: Mr. I

• Age: 35

• Date of Birth: 15/03/1988

• Sex: Male

• Education: Bachelor’s degree in Marketing

• Residence: Urban, lives with spouse and one child

• Family Structure: Nuclear

• Mother Tongue: English

• Religion: Christian

REFERRAL DETAILS

• Referral Source: Brought by his spouse due to mood swings and erratic behavior.

• Informant Details:

o Name: Mrs. I (Spouse)

o Relationship with Client: Spouse

o Adequacy: Adequate

o Reliability: Reliable

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PRESENTING COMPLAINTS

• According to Informant:

o Experiences extreme mood swings, from periods of high energy and euphoria

to deep depression.

o During high-energy periods, engages in risky behaviors like excessive

spending and impulsive decisions.

o During depressive periods, withdraws from social interactions and neglects

personal responsibilities.

• According to Client:

o Admits to mood swings but feels unable to control them.

o Reports feeling euphoric and invincible during high-energy periods and

hopeless during depressive periods.

HISTORY OF PRESENTING ILLNESS (HOPI)

• Duration: 8 years

• Mode of Onset: Gradual

• Course: Episodic

Body of HOPI:

Mr. I, a 35-year-old male, has been experiencing extreme mood swings for the past eight

years, marked by alternating episodes of mania and depression. The initial symptoms were

noticed after a period of intense work-related stress, which seemed to have triggered his first

manic episode. During this phase, he exhibited excessive energy, a decreased need for sleep,

and an inflated sense of self-worth. He engaged in impulsive behaviors, including extravagant

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spending sprees, taking uncalculated risks, and making reckless financial decisions. He

described feeling invincible, capable of achieving anything, and believed he had

extraordinary abilities. These episodes would last for weeks, followed by a sudden crash into

a depressive phase.

During depressive episodes, Mr. I experiences persistent sadness, a lack of interest in

previously enjoyable activities, and a significant drop in energy levels. He finds it difficult to

concentrate, often struggles to make decisions, and experiences overwhelming feelings of

worthlessness. He withdraws from social interactions, avoiding both friends and family. His

personal hygiene deteriorates, and he neglects responsibilities at home and work. He often

describes these episodes as “falling into a pit of hopelessness,” and has had occasional

thoughts of self-harm, although he denies any suicidal attempts.

Mr. I’s impulsive decisions during manic episodes have led to financial instability and

difficulties in maintaining professional responsibilities. He has changed jobs multiple times,

often leaving positions abruptly during manic phases, believing he was destined for greater

success elsewhere. However, during depressive phases, he struggles to maintain productivity,

resulting in a cycle of career instability.

His spouse has observed an increase in irritability and restlessness during manic phases,

noting that he often gets into arguments, particularly when his judgment or decisions are

questioned. Despite recognizing the harmful impact of these mood swings on his life, Mr. I

has never sought medical help before. He reports that the episodes have become more intense

in recent years, prompting his spouse to seek professional assistance.

• Precipitating Factors: Work-related stress, underlying predisposition due to family

history.

NEGATIVE HISTORY

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• No history of substance abuse.

• No history of head trauma or neurological disorders.

• No history of chronic medical illness.

MEDICAL HISTORY

• No significant medical or surgical history.

• No known allergies or chronic illnesses.

PAST PSYCHIATRIC HISTORY

• No prior psychiatric treatment or hospitalization.

FAMILY HISTORY

Mr. I was raised in a middle-class nuclear family. His father had a history of mood swings

and impulsive behaviors, later diagnosed as bipolar disorder. His mother and younger sister

have no known psychiatric conditions. His family has been supportive but has expressed

concern over his erratic behavior and financial instability.

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PERSONAL HISTORY

• Date of Birth: 15/03/1988

• Place of Birth: Not elicited

• Birth History: Full-term normal delivery

• Delivery Type: Normal

• Birth Cry: Present

• Mother’s Condition During Pregnancy: No complications reported

• Postnatal History: Normal

• Physical Health During Infancy: Normal

• Developmental Milestones: Achieved on time

• Neurotic Symptoms in Childhood: Not elicited

• Night Terrors: Not elicited

• Behavioral Problems During Childhood: Not reported

• Home Atmosphere During Childhood: Satisfactory

• Emotional Problems in Adolescence: Not reported

• Parental Lack: Not elicited

• Anomalous Family Situations: None reported

EDUCATIONAL HISTORY

• Age of Beginning School: Not elicited

• Academic Performance: Excellent

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• Special Abilities/Disabilities: None reported

• Number of Friends: Many

• Relationship with Friends: Good

• Co-curricular Activities: Active in sports

• Hobbies and Interests: Marketing and technology

OCCUPATIONAL HISTORY

• Age of Starting Work: Not elicited

• Work Record: Erratic due to mood instability

• Past Job: Multiple job changes due to impulsive resignations

• Present Job: Marketing professional with inconsistent performance

• Job Satisfaction: Fluctuates with mood swings

MARITAL HISTORY

• Spouse’s Age: Not elicited

• Duration of Marriage: 10 years

• Occupation of Spouse: Not elicited

• Personality: Supportive but distressed

• Compatibility: Initially good, currently strained due to mood instability

PREMORBID PERSONALITY

• Social Relations: Extroverted, many friends

• Intellectual Activities: Interested in marketing and technology

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• Mood: Generally stable but prone to mood swings

• Character: Responsible but impulsive

• Fantasy Life: Minimal daydreaming

• Habits: Irregular sleep and eating patterns, disrupted by mood swings; no reported

use of tobacco or recreational drugs

MENTAL STATUS EXAMINATION

General Appearance and Behavior

• Appearance: Looking one’s age.

• Level of Grooming: Shabbily dressed during depressive episodes; overly groomed

during manic episodes.

• Level of Cleanliness: Inadequate during depressive episodes; overtly clean during

manic episodes.

• Level of Consciousness: Fully conscious and alert.

• Mode of Entry: Came willingly.

• Cooperativeness: Less than normal during depressive episodes; more than normal

during manic episodes.

• Eye-to-Eye Contact: Not maintained during depressive episodes; overly intense

during manic episodes.

• Psychomotor Activity: Decreased during depressive episodes; increased restlessness

and agitation during manic episodes.

• Empathy: Difficult to establish during depressive episodes; overly familiar during

manic episodes.
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• Quality of Rapport: Poor during depressive episodes; overly familiar during manic

episodes.

• Gesturing: Normal during depressive episodes; exaggerated during manic episodes.

• Posturing: Normal posture.

• Other Movements: None (no mannerisms, stereotypes, tremors, EPS, AIMS, or

perseveration).

• Other Catatonic Phenomena: None (no automatic obedience, negativism, waxy

flexibility, echopraxia, or echolalia).

Speech

• Initiation: Speaks when spoken to during depressive episodes; spontaneous and rapid

during manic episodes.

• Reaction Time: Delayed during depressive episodes; shortened during manic

episodes.

• Speed: Slow during depressive episodes; rapid during manic episodes.

• Output: Decreased during depressive episodes; increased during manic episodes.

• Pressure of Speech: Absent during depressive episodes; present during manic

episodes.

• Volume: Soft during depressive episodes; loud during manic episodes.

• Tone: Monotonous during depressive episodes; variable during manic episodes.

• Manner: Normal during depressive episodes; inappropriately familiar during manic

episodes.

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• Relevance: Fully relevant during depressive episodes; sometimes off target during

manic episodes.

• Stream: Normal during depressive episodes; tangential during manic episodes.

• Coherence: Fully coherent during depressive episodes; over-elaborate and digressive

during manic episodes.

• Others: None (no rhyming, punning, echolalia, perseveration, or neologism).

• Sample of Speech:

o Depressive Episode: “I feel worthless… I can’t do anything right.”

o Manic Episode: “I have so many ideas! I’m going to start a new business and

change the world!”

Thought

• Tempo: Retarded thinking during depressive episodes; racing thoughts during manic

episodes.

• Form: Adequate during depressive episodes; loosening of associations during manic

episodes.

• Obsession: None.

• Compulsion: None.

• Thought Alienation Phenomena: None (no thought insertion, withdrawal, or

broadcast).

• Thought Commentary: None.

• Thought Contents:

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o Depressive Episode: Worthlessness, helplessness, hopelessness, guilt.

o Manic Episode: Grandiose ideas, overconfidence, and invincibility.

• Example:

o Depressive Episode: “I’m a failure… I don’t deserve to live.”

o Manic Episode: “I’m the best at everything… I can do anything!”

Mood

• Subjective:

o Depressive Episode: “I feel empty and hopeless.”

o Manic Episode: “I feel euphoric and unstoppable.”

• Objective:

o Depressive Episode: Depressed and tearful.

o Manic Episode: Euphoric and irritable.

• Predominant Mood State: Depressed during depressive episodes; euphoric during

manic episodes.

• Other Major Moods: Anxious during depressive episodes; irritable during manic

episodes.

• Range: Restricted during depressive episodes; expansive during manic episodes.

• Reactivity: Non-reactive during depressive episodes; overly reactive during manic

episodes.

• Quality of Mood: Sad and flat during depressive episodes; elevated and labile during

manic episodes.

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• Communicability: Poor during depressive episodes; excessive during manic

episodes.

• Lability: None during depressive episodes; present during manic episodes.

• Appropriateness: Appropriate to thought content.

• Congruence: Mood congruent.

• Emotional Expression: Blunted during depressive episodes; exaggerated during

manic episodes.

Perception

• Hallucination: None.

• Illusion: None.

• Depersonalization: None.

• Déjà Vu Phenomena: None.

• Somatic Passivity: None.

• Special: None (no made acts).

Cognitive Functions

• Attention: Normally aroused during manic episodes; aroused with difficulty during

depressive episodes.

• Digit Forward: 5/5 during manic episodes; 4/5 during depressive episodes.

• Digit Backward: 4/5 during manic episodes; 2/5 during depressive episodes.

• Concentration: Normally sustained during manic episodes; sustained with difficulty

during depressive episodes.

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• 100-7 Test: 93, 86, 79, 72, 65 (completed without difficulty during manic episodes;

with difficulty during depressive episodes).

• 40-3 Test: 37, 34, 31, 28, 25 (completed without difficulty during manic episodes;

with difficulty during depressive episodes).

• 20-1 Test: 19, 18, 17, 16, 15 (completed without difficulty during manic episodes;

with difficulty during depressive episodes).

• Months Backwards: Completed without difficulty during manic episodes;

incomplete during depressive episodes.

• Weekdays Backwards: Completed without difficulty during manic episodes;

incomplete during depressive episodes.

Orientation

• Time: Approximate time (knows day, date, month, and year).

• Place: Kind of place (knows he is in a clinic).

• Person: Self and close associates (recognizes himself and family members).

Memory

• Immediate: 3/3 objects recalled immediately.

• Recent: Recalls last meal and visitors.

• Verbal Recall:

o After 5 minutes: 3/3 objects.

o After 10 minutes: 3/3 objects.

• Visual Recall: 3/3 objects recalled.

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• Remote: Recalls personal and impersonal events accurately.

Intelligence

• Comprehension: Understands simple and complex commands.

• Vocabulary: Good (can name common and uncommon objects).

• Arithmetic Ability: Adequate (can perform mental arithmetic).

• General Fund of Information:

o Literate: Knows the name of the Prime Minister, 5 rivers, cities, states, and

capitals of countries.

o Current Events: Aware of major current events.

Abstraction

• Interpretation of Proverbs: Concrete.

o “A stitch in time saves nine” interpreted as “Sewing saves clothes.”

• Similarities Between Paired Objects: Concrete.

o “Apple and orange” interpreted as “Both are fruits.”

• Dissimilarities Between Paired Objects: Concrete.

o “Book and TV” interpreted as “One is for reading, the other is for watching.”

Judgment

• Personal: Impaired during both episodes (unable to plan for the future due to mood

swings).

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• Social: Intact during depressive episodes; impaired during manic episodes (disregards

social norms).

• Test: Impaired during both episodes (predicts negative outcomes in imaginary

situations).

Insight

• Awareness of Abnormal Behavioral/Experience: Yes.

• Attribution to Physical Causes: No.

• Recognition of Personal Responsibility: Yes.

• Willingness to Take Treatment: Yes.

• Grade: 3 (Awareness of being sick, but attributes it to external factors).

• Motivation/Willingness for Treatment: Motivated but feels overwhelmed by

symptoms.

DIAGNOSTIC FORMULATION

• Major Diagnosis: Bipolar Affective Disorder (Type I).

• Differential Diagnosis: Major Depressive Disorder, Borderline Personality Disorder.

• Associated Diagnoses: None.

PSYCHOPATHOLOGY

Mr. I, a 38-year-old male, presents with a history of recurrent mood disturbances

characterized by alternating episodes of mania and depression, indicative of Bipolar Affective

Disorder (BPAD). During manic episodes, he exhibits elevated mood, grandiosity, excessive

talkativeness, and impulsive behaviors, including reckless financial decisions and

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interpersonal conflicts. His speech is pressured, with frequent flight of ideas and

distractibility, leading to impaired occupational functioning. In contrast, depressive episodes

manifest as pervasive sadness, psychomotor retardation, reduced speech output, and suicidal

ideation, though no attempts have been reported. His insight remains poor during mania but

improves partially during depressive phases. These mood fluctuations have significantly

impacted his social relationships and work stability, necessitating long-term psychiatric

management.

PSYCHOTHERAPY AND MANAGEMENT

• Medications: Mood stabilizers (e.g., Lithium), Antipsychotics (e.g., Olanzapine) for

manic episodes.

• Therapy: Cognitive Behavioral Therapy (CBT) and psychoeducation.

• Social Support: Family counseling and support groups for bipolar disorder.

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CASE HISTORY 9

SOCIO-DEMOGRAPHIC DATA

Name: Ms. J

Age: 30

Date of Birth: 20/06/1993

Sex: Female

Education: Bachelor’s degree in Nursing

Occupation: Unemployed (previously worked as a nurse)

Annual Income: Not applicable (currently unemployed)

Marital Status: Single

Residence: Urban, lives alone

Mother Tongue: Kannada

Religion: Christian

REFERRAL DETAILS

Referral Source: Referred by her family physician due to symptoms of anxiety and

flashbacks.

Informant Details:

Name: Mrs. J (mother)

Relationship with Client: Mother

Acquaintance: Adequate

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Adequacy: Adequate

Reliability: Reliable

PRESENTING COMPLAINTS

According to Informant:

Experiences flashbacks and nightmares related to a traumatic event.

Avoids situations that remind her of the trauma.

Reports feeling anxious and on edge most of the time.

According to Client:

Admits to experiencing flashbacks and nightmares but feels unable to control them.

Reports feeling anxious and on edge, with difficulty sleeping and concentrating.

HISTORY OF PRESENTING ILLNESS (HOPI)

Duration: 3 years

Mode of Onset: Acute

Course: Continuous

Body of HOPI:

Ms. J, a 30-year-old female with a bachelor’s degree in Nursing, presented with a 3-year

history of symptoms consistent with Post-Traumatic Stress Disorder (PTSD). The symptoms

began after she witnessed a violent assault at her workplace. Initially, she experienced mild

anxiety and occasional flashbacks, which she tried to manage on her own. However, over

time, her symptoms worsened, and she began to experience recurrent flashbacks and

nightmares related to the traumatic event.

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Ms. J described the flashbacks as vivid and intrusive, often triggered by reminders of the

trauma, such as loud noises or crowded places. She reported feeling as though she was

reliving the event, with intense feelings of fear and helplessness. These flashbacks were often

accompanied by physical symptoms such as sweating, rapid heartbeat, and shortness of

breath. She also experienced frequent nightmares, which disrupted her sleep and left her

feeling exhausted and on edge during the day.

To cope with her symptoms, Ms. J began avoiding situations that reminded her of the trauma.

She stopped going to her workplace and avoided crowded places, public transport, and social

gatherings. She described feeling anxious and hypervigilant most of the time, constantly

scanning her environment for potential threats. This heightened state of alertness made it

difficult for her to relax or concentrate on daily tasks.

Ms. J made several attempts to return to work but found herself overwhelmed by anxiety and

fear. She reported feeling guilty and ashamed about her inability to move on from the trauma,

often blaming herself for not being strong enough. She also expressed feelings of isolation, as

she had withdrawn from friends and colleagues due to her avoidance behaviors.

Despite recognizing the impact of her symptoms on her life, Ms. J had never sought

professional help before. She initially tried to cope by distracting herself with household

chores and spending time with her family. However, as her condition worsened, she felt

increasingly hopeless and overwhelmed. It was only after persistent encouragement from her

family and her family physician that she agreed to seek treatment.

Precipitating Factors: Witnessing a violent assault at her workplace.

NEGATIVE HISTORY

No history of substance abuse or medical illness.

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MEDICAL HISTORY

Illness: Not elicited

Operation: Not applicable

Accidents: Not elicited

Surgical problem: Not applicable

PAST PSYCHIATRIC HISTORY

Information of client's past psychiatric record: Not applicable

Dates: Not applicable

Duration: Not applicable

Symptoms: Not applicable

Diagnosis: Not applicable

Treatment: Not applicable

FAMILY HISTORY

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Ms. J comes from a nuclear family consisting of her father, mother, and one older brother.

Her father is alive and has no history of psychiatric illness. Her mother is also alive and in

good health, with no known mental health issues. Her older brother is healthy and has no

history of psychiatric or medical illness. The family is of middle-class socioeconomic status

and is described as supportive but concerned about Ms. J’s condition. There is no family

history of psychiatric illness or other significant medical conditions.

PERSONAL AND DEVELOPMENTAL HISTORY

Date of Birth: 20/06/1993

Place of Birth: Urban area

Birth history: Full-term normal delivery

Delivery type: Normal

Birth cry: Normal

Mother’s condition during pregnancy: No complications

Postnatal history: Not elicited

Physical health during infancy: Normal

Delay in milestone development: Not elicited

Motor: Not elicited

Adaptive: Not elicited

Speech: Not elicited

Social: Not elicited

Neurotic symptoms in childhood: Not elicited

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Night terrors: Not elicited

Behavior problems during childhood: Not elicited

Habits during childhood: Not elicited

Childhood health: Normal

Home atmosphere during childhood: Satisfactory

Emotional problem in adolescence: Not elicited

Home atmosphere during adolescence: Satisfactory

Parental lack: Not elicited

Anomalous family situation: Not elicited

EDUCATIONAL HISTORY

Age of beginning school: 5 years

Special abilities/disabilities: Not elicited

Academic performance: Excellent

Number of friends: Many

Relationship with friends: Good

Co-curricular activities: Active in extracurricular activities

Hobbies and interests: Reading and music

OCCUPATIONAL HISTORY

Age of starting work: 23 years

Work record: Satisfactory (previously worked as a nurse)

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Past job: Nurse

Present job: Unemployed

Job satisfaction: Not applicable

MENSTRUAL HISTORY

Age of Menarche: 13 years

Regularity/duration: Regular, 5 days

Amount of physical pain: Mild

Emotional problems if any: Not elicited

SEXUAL INCLINATIONS AND PRACTICE

Sexual information acquired through: Not elicited

Masturbation/Sexual fantasies: Not elicited

Homosexuality/heterosexuality: Heterosexual

Sexual problems if any: Not elicited

MARITAL HISTORY

Spouse age: Not applicable

Duration of marriage: Not applicable

Occupation: Not applicable

Personality: Not applicable

Compatibility: Not applicable

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PREMORBID PERSONALITY

Social relations with:

Family: Extroverted, many friends

Friends: Good relationships

Relatives: Not elicited

Societies: Not elicited

Workmates: Good relationships

Intellectual activities:

Hobbies: Reading and music

Interests: Nursing and healthcare

Memory: Good

Observation: Good

Judgment: Good

Mood of client: Generally stable but prone to anxiety

Character: Responsible and compassionate

Fantasy life: Minimal daydreaming

Habits:

Eating: Regular

Alcohol consumption: Not elicited

Self-medication: Not elicited

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Tobacco consumption: Not elicited

Sleeping patterns: Disrupted by anxiety

Excretory functions: Normal

Use of other recreational drugs: Not elicited

Mental Status Examination

General Appearance and Behavior

• Appearance: Looking one’s age.

• Level of Grooming: Normal.

• Level of Cleanliness: Adequate.

• Level of Consciousness: Fully conscious and alert.

• Mode of Entry: Came willingly.

• Cooperativeness: Normal.

• Eye-to-Eye Contact: Difficult.

• Psychomotor Activity: Increased restlessness, agitation.

• Empathy: Spontaneous.

• Quality of Rapport: Good.

• Gesturing: Normal.

• Posturing: Normal posture.

• Other Movements: None (no mannerisms, stereotypes, tremors, EPS, AIMS, or

perseveration).

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• Other Catatonic Phenomena: None (no automatic obedience, negativism, waxy

flexibility, echopraxia, or echolalia).

• Impression: Intact (no significant abnormalities in general behavior).

Speech

• Initiation: Speaks when spoken to.

• Reaction Time: Delayed.

• Speed: Normal.

• Output: Decreased.

• Pressure of Speech: Absent.

• Volume: Normal.

• Tone: Monotonous.

• Manner: Normal.

• Relevance: Fully relevant.

• Stream: Normal.

• Coherence: Fully coherent.

• Others: None (no rhyming, punning, echolalia, perseveration, or neologism).

• Sample of Speech: “I feel nervous when I have to talk to people… I’m afraid they’ll

judge me.”

• Impression: Intact (speech is coherent and relevant).

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Thought

• Tempo: Normal.

• Form: Adequate.

• Obsession: None.

• Compulsion: None.

• Thought Alienation Phenomena: None (no thought insertion, withdrawal, or

broadcast).

• Thought Commentary: None.

• Thought Contents:

o Idea: Fear of social judgment, embarrassment, and humiliation.

o Overvalued Idea: None.

o Delusion: None.

o Example: “I feel like everyone is watching me and judging me.”

• Impression: Intact (no formal thought disorder; thought content reflects anxiety).

Mood

• Subjective: “I feel anxious and nervous around people.”

• Objective: Anxious and apprehensive.

• Predominant Mood State: Anxious.

• Other Major Moods: None.

• Range: Restricted.

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• Reactivity: Reactive.

• Quality of Mood: Anxious and tense.

• Communicability: Good.

• Lability: None.

• Appropriateness: Appropriate to thought content.

• Congruence: Mood congruent.

• Emotional Expression: Normal.

• Impression: Intact (mood is congruent with affect and thought content).

Perception

• Hallucination: None.

• Illusion: None.

• Depersonalization: None.

• Déjà Vu Phenomena: None.

• Somatic Passivity: None.

• Special: None (no made acts).

• Impression: Intact (no perceptual abnormalities).

Cognitive Functions

• Attention: Normally aroused.

• Digit Forward: 5/5.

• Digit Backward: 4/5.

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• Concentration: Normally sustained.

• 100–7 Test: 93, 86, 79, 72, 65 (completed without difficulty).

• 40–3 Test: 37, 34, 31, 28, 25 (completed without difficulty).

• 20–1 Test: 19, 18, 17, 16, 15 (completed without difficulty).

• Names of Months (Backwards): Completed without difficulty.

• Names of Weekdays (Backwards): Completed without difficulty.

• Impression: Intact (attention and concentration are preserved).

Orientation

• Time: Approximate time (knows day, date, month, and year).

• Place: Kind of place (knows she is in a clinic).

• Person: Self and close associates (recognizes herself and family members).

• Impression: Intact (oriented to time, place, and person).

Memory

• Immediate: 3/3 objects recalled immediately.

• Recent: Recalls last meal and visitors.

• Verbal Recall:

o After 5 minutes: 3/3 objects.

o After 10 minutes: 3/3 objects.

• Visual Recall: 3/3 objects recalled.

• Remote: Recalls personal and impersonal events accurately.

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• Impression: Intact (memory is preserved).

Intelligence

• Comprehension: Understands simple and complex commands.

• Vocabulary: Good (can name common and uncommon objects).

• Arithmetic Ability: Adequate (can perform mental arithmetic).

• General Fund of Information:

o Literate: Knows the name of the Prime Minister, 5 rivers, cities, states, and

capitals of countries.

o Current Events: Aware of major current events.

• Impression: Intact (intelligence is within normal limits).

Abstraction

• Interpretation of Proverbs: Concrete.

o “A stitch in time saves nine” interpreted as “Sewing saves clothes.”

• Similarities Between Paired Objects: Concrete.

o “Apple and orange” interpreted as “Both are fruits.”

• Dissimilarities Between Paired Objects: Concrete.

o “Book and TV” interpreted as “One is for reading, the other is for watching.”

• Impression: Not Intact (abstract thinking is concrete).

Judgment

• Personal: Impaired (unable to plan for the future due to preoccupation with anxiety).

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• Social: Impaired (avoids social situations due to fear of judgment).

• Test: Impaired (predicts negative outcomes in social situations).

• Impression: Not Intact (impaired judgment due to anxiety and avoidance behaviors).

Insight

• Awareness of Abnormal Behavioral/Experience: Yes.

• Attribution to Physical Causes: No.

• Recognition of Personal Responsibility: Yes.

• Willingness to Take Treatment: Yes.

• Grade: 5 (Intellectual insight: Awareness of being ill and that the symptoms are due

to irrational thoughts, yet does not apply this to current experiences).

• Motivation/Willingness for Treatment: Motivated and willing to engage in therapy.

DIAGNOSTIC FORMULATION

Major Diagnosis: Post-Traumatic Stress Disorder (PTSD).

Differential Diagnosis: Generalized Anxiety Disorder, Major Depressive Disorder.

Associated Diagnoses: None.

PSYCHOTHERAPY AND MANAGEMENT

Medications: Selective Serotonin Reuptake Inhibitors (SSRIs) (e.g., Sertraline).

Therapy: Cognitive Behavioral Therapy (CBT) with trauma-focused interventions.

Social Support: Support groups for PTSD and family counseling.

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CASE HISTORY 10

SOCIO-DEMOGRAPHIC DATA

• Name: Ms. K

• Age: 28

• Date of Birth: 05/11/1995

• Sex: Female

• Education: Bachelor’s degree in Fine Arts

• Residence: Urban, lives alone

• Family Structure: Single

• Mother Tongue: English

• Religion: Christian

REFERRAL DETAILS

• Referral Source: Self-referred due to emotional instability and relationship

difficulties.

• Informant Details:

o Name: None (self-referred)

o Relationship with Client: Self

o Adequacy: Adequate

o Reliability: Reliable

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PRESENTING COMPLAINTS

• According to Client:

o Intense mood swings and difficulty managing emotions.

o Struggles with unstable relationships and fear of abandonment.

o Engages in self-harming behaviors and has a history of suicidal ideation.

HISTORY OF PRESENTING ILLNESS (HOPI)

• Duration: 10 years

• Mode of Onset: Gradual

• Course: Continuous

• Body of HOPI:

Ms. K, a 28-year-old female with a bachelor’s degree in Fine Arts, has been experiencing

persistent emotional instability, impulsivity, and difficulties in interpersonal relationships for

the past decade. Her symptoms began in late adolescence and have remained constant,

significantly affecting her daily life. She describes experiencing rapid mood fluctuations,

shifting between intense anger, sadness, and anxiety, often triggered by perceived rejection or

interpersonal conflicts. Ms. K struggles with maintaining stable relationships, frequently

swinging between idealizing and devaluing her partners. Her pervasive fear of abandonment

often leads to desperate efforts to prevent perceived rejection, even at the cost of personal

well-being. She reports feeling emotionally overwhelmed, helpless, and out of control, with

an enduring sense of emptiness when alone.

She engages in self-harming behaviors, including cutting, as a way to cope with her distress

and emotional pain. Although she has experienced multiple episodes of suicidal ideation, she

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denies any prior suicide attempts. She acknowledges that her impulsive behaviors negatively

impact her life but feels unable to regulate them effectively. Additionally, she reports identity

disturbance, frequently changing her interests, goals, and aspirations. She struggles with a

persistent sense of confusion about her self-worth and purpose, exacerbating her distress. Her

difficulty in controlling anger has led to frequent outbursts, damaging her relationships with

friends and family. People close to her have expressed concern over her emotional reactivity,

but she has never sought professional help before. However, due to the worsening nature of

her symptoms, she now feels compelled to seek intervention.

The onset of her symptoms appears closely linked to childhood trauma, particularly

emotional neglect, and growing up with a father who struggled with alcohol use disorder.

These early experiences may have contributed to her difficulties in emotional regulation and

interpersonal relationships.

NEGATIVE HISTORY

• No history of substance abuse or medical illness.

MEDICAL HISTORY

• No significant medical or surgical history.

PAST PSYCHIATRIC HISTORY

• No prior psychiatric treatment or hospitalization.

FAMILY HISTORY

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Ms. K was raised in a middle-class nuclear family of four members. Her father who is a

contracter has a history of alcohol use disorder, which contributed to a turbulent home

environment. While her mother and younger brother do not have any known psychiatric

history, she describes her childhood as emotionally neglectful, particularly due to her father’s

struggles with alcoholism. Although her family was financially stable, her emotional needs

were often unmet, which may have contributed to her current difficulties with emotional

regulation and attachment. However, her relationships with them have been strained due to

her emotional outbursts and impulsive behaviors. She continues to maintain contact with her

mother and brother, though her relationship with her father remains distant.

PERSONAL AND DEVELOPMENTAL HISTORY

• Parental Attitude Towards Pregnancy: Wanted

• Mother’s Health During Pregnancy: No complications.

• Nature of Birth: Full-term normal delivery.

• Birth Cry: Normal

• Feeding Habits in Early Childhood: Breastfed.

• Developmental Milestones: Achieved normally.

o Motor: Normal

o Adaptive: Normal

o Speech: Normal

o Social: Normal

• Health During Childhood: No significant illnesses.

• Schooling: Average academic performance, active in arts.

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• Neurotic Symptoms in Childhood: None elicited

• Night Terrors: None reported

• Behavior Problems in Childhood: None significant

• Habits in Childhood: No unusual habits reported

• Home Atmosphere in Childhood: Satisfactory

• Emotional Problems in Adolescence: Difficulty with identity, fear of abandonment

• Home Atmosphere in Adolescence: Satisfactory

• Parental Lack: Emotional neglect from father

• Anomalous Family Situation: Alcohol use disorder in father

EDUCATIONAL HISTORY

Ms. K completed her schooling with average academic performance but showed a strong

inclination towards arts and creative subjects. She pursued a Bachelor’s degree in Fine Arts,

which allowed her to express herself creatively. Throughout her education, she faced

emotional instability, which at times affected her academic consistency. Despite these

struggles, she successfully completed her degree and has been employed in the creative field

for over five years. However, due to her emotional difficulties, she has faced challenges in

maintaining professional relationships and consistent productivity.

OCCUPATIONAL HISTORY

• Age of Starting Work: 23

• Work Record: Satisfactory, but challenges due to emotional instability

• Past Job: Freelance artist

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• Present Job: Graphic designer

• Job Satisfaction: Moderate, affected by emotional instability

MENSTRUAL HISTORY

• Age of Menarche: 13

• Regularity/Duration: Regular

• Amount of Physical Pain: Mild

• Emotional Problems: Mood swings, irritability

SEXUAL HISTORY

• Sexual Information Acquired Through: Peers, internet

• Masturbation/Sexual Fantasies: Not elicited

• Homosexuality/Heterosexuality: Heterosexual

• Sexual Problems: None reported

PREMORBID PERSONALITY

• Social Relations: Intense and unstable relationships.

• Intellectual Activities: Interested in fine arts and creative writing.

• Mood: Generally unstable, prone to mood swings.

• Character: Impulsive and emotionally sensitive.

• Fantasy Life: Moderate daydreaming.

• Habits:

o Eating: Irregular

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o Alcohol Consumption: Occasional

o Self-Medication: None reported

o Tobacco Consumption: None

o Sleeping Patterns: Irregular

o Excretory Functions: Normal

o Use of Other Recreational Drugs: None reported

MENTAL STATUS EXAMINATION

General Appearance and Behavior

Appearance: Looking one’s age.

Level of Grooming: Normal.

Level of Cleanliness: Adequate.

Level of Consciousness: Fully conscious and alert.

Mode of Entry: Came willingly.

Cooperativeness: Normal.

Eye-to-Eye Contact: Maintained but hesitant.

Psychomotor Activity: Normal.

Empathy: Spontaneous.

Quality of Rapport: Good.

Gesturing: Normal.

Posturing: Normal posture.

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Other Movements: None (no mannerisms, stereotypes, tremors, EPS, AIMS, or

perseveration).

Other Catatonic Phenomena: None (no automatic obedience, negativism, waxy flexibility,

echopraxia, or echolalia).

Speech

Initiation: Speaks when spoken to.

Reaction Time: Normal.

Speed: Normal.

Output: Normal.

Pressure of Speech: Absent.

Volume: Normal.

Tone: Monotonous.

Manner: Normal.

Relevance: Fully relevant.

Stream: Normal.

Coherence: Fully coherent.

Others: None (no rhyming, punning, echolalia, perseveration, or neologism).

Sample of Speech: Responds clearly but hesitantly, “I feel like no one understands me… I’m

always alone.”

Impression: Speech intact

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Thought

Tempo: Normal.

Form: Adequate.

Obsession: None.

Compulsion: None.

Thought Alienation Phenomena: None (no thought insertion, withdrawal, or broadcast).

Thought Commentary: None.

Thought Contents:

Idea: Fear of abandonment, self-worth, and identity disturbance.

Overvalued Idea: None.

Delusion: None.

Sample: “I feel like I don’t know who I am… I’m always changing.”

Impression: Thought is intact

Mood

Subjective: “I feel anxious and irritable most of the time.”

Objective: Anxious and irritable.

Predominant Mood State: Anxious.

Other Major Moods: Irritable.

Range: Restricted.

Reactivity: Reactive.

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Quality of Mood: Tense.

Communicability: Good.

Lability: Present (mood swings).

Appropriateness: Appropriate to thought content.

Congruence: Mood congruent.

Emotional Expression: Normal.

Impression: Mood is congruent to Affect

Perception

Hallucination: None.

Illusion: None.

Depersonalization: None.

Déjà Vu Phenomena: None.

Somatic Passivity: None.

Special: None (no made acts).

Impression: Perception intact

Cognitive Functions

Attention: Normally aroused.

Digit Forward: 5/5.

Digit Backward: 4/5.

Concentration: Normally sustained.

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100-7 Test: 93, 86, 79, 72, 65 (completed without difficulty).

40-3 Test: 37, 34, 31, 28, 25 (completed without difficulty).

20-1 Test: 19, 18, 17, 16, 15 (completed without difficulty).

Months Backwards: Completed without difficulty.

Weekdays Backwards: Completed without difficulty.

Impression: Cognitive functions intact

Orientation

Time: Approximate time (knows day, date, month, and year).

Place: Kind of place (knows she is in a clinic).

Person: Self and close associates (recognizes herself and family members).

Speech Sample:

"Today is Tuesday, October 10th, 2023. I’m at the clinic for my appointment. I came here

with my daughter, Sarah, and my husband, John, is at work. I know who I am, and I

recognize my family members."

Impression: Orientation to time, place and person intact

Memory

Immediate: 3/3 objects recalled immediately.

asked to remember three objects: apple, table, and umbrella

Recent: Recalls last meal and visitors.

For breakfast, I had toast and tea. My friend Linda visited me yesterday afternoon.

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Verbal Recall:

After 5 minutes: 3/3 objects.

Asked to remember apple, table, and umbrella.

Visual Recall: 3/3 objects recalled.

showed picture with a tree, a car, and a book

Remote: Recalls personal and impersonal events accurately.

Sample: I was born 1995. I also remember when the first man landed on the moon—it was in

1969

Impression: Memory intact

Intelligence

Comprehension: Understands simple and complex commands.

Sample: If I found a stamped, addressed envelope on the ground, I would mail it to the

address written on it.

Vocabulary: Good

Arithmetic Ability: Adequate

General Fund of Information:

Literate: Knows the name of the Prime Minister, 5 rivers, cities, states, and capitals of

countries.

Current Events: Aware of major current events.

Sample: I heard on the news that there was a major earthquake in Morocco recently.

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Impression: Intelligence average

Abstraction

Interpretation of Proverbs: Concrete

Sample: “A stitch in time saves nine” interpreted as “A stitch in time saves nine" means "If

you fix something right away, it won’t get worse later”

Similarities Between Paired Objects: Concrete

Sample: Apple and orange interpreted as “An apple and an orange are both fruits that you can

eat”

Dissimilarities Between Paired Objects: Concrete

Sample: Book and TV interpreted as a book is for reading, and a TV is for watching shows

Impression: Abstraction is concrete

Judgment

Personal: Impaired

"If I ran out of my medication, I would wait until my next appointment to ask for more."

Social: Impaired

"If I saw someone stealing in a store, I would ignore it because it’s not my problem."

Test: Impaired

"If I found a stamped letter on the ground, I would throw it away because it’s not mine."

Impression: Judgement not intact

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Insight

Awareness of Abnormal Behavioral/Experience: Yes.

Attribution to Physical Causes: No.

Recognition of Personal Responsibility: Yes.

Willingness to Take Treatment: Yes.

Grade: 3 (Awareness of being sick, but attributes it to external factors).

Motivation/Willingness for Treatment: Motivated but feels overwhelmed by symptoms.

DIAGNOSTIC FORMULATION

Major Diagnosis: Borderline Personality Disorder (BPD).

Differential Diagnosis: Bipolar Disorder, Major Depressive Disorder.

Associated Diagnoses: None.

PSYCHOPATHOLOGY

Ms. K presents with a chronic pattern of emotional dysregulation, impulsivity, and unstable

interpersonal relationships, consistent with Borderline Personality Disorder (BPD). Her

history reveals intense mood swings, fear of abandonment, self-harm, and identity

disturbance, which have significantly impacted her daily functioning. Her emotional

instability appears rooted in childhood trauma, particularly emotional neglect and a turbulent

family environment due to her father's alcohol use disorder. Despite intact cognitive and

perceptual functions, she exhibits impaired judgment and concrete thinking. Her insight is

partial, recognizing her distress but attributing it to external factors. Given her symptoms, a

treatment plan involving Dialectical Behavior Therapy (DBT) and possible pharmacological

support is recommended.

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PSYCHOTHERAPY AND MANAGEMENT

Medications: Mood stabilizers (e.g., Lamotrigine) and SSRIs (e.g., Fluoxetine) if depressive

symptoms are present.

Therapy: Dialectical Behavior Therapy (DBT) for emotion regulation and interpersonal

effectiveness.

Social Support: Group therapy and family counseling.

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CHILD CASE
HISTORY

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CASE HISTORY 1

SOCIO-DEMOGRAPHIC DATA

• Name: S.K.

• Age: 6 years

• Date of Birth: 12/08/2017

• Sex: Male

• Education: 1st Standard

• Residence: No. 23, Rajajinagar, Bangalore, Karnataka

• Family Structure: Nuclear family (parents and child)

• Mother Tongue: Kannada

• Religion: Hindu

REFERRAL DETAILS

• Referral Source: School

• Informant Details:

o Name: R.K. (Mother)

o Relationship with Client: Mother

o Acquaintance: Lifelong

o Adequacy: Good

o Reliability: Good

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PRESENTING COMPLAINTS

• According to Informant (Mother):

o Delayed speech and language development.

o Poor eye contact.

o Repetitive behaviors (e.g., hand flapping, rocking).

o Difficulty interacting with peers.

o Fixation on specific objects (e.g., spinning wheels of toys).

o Resistance to changes in routine.

• According to Client: Not elicited (child is nonverbal).

HISTORY OF PRESENTING ILLNESS (HOPI)

• Duration: Since early childhood

• Mode of Onset: Insidious

• Course: Continuous

Body of HOPI:

S.K., a 6-year-old male, has been brought to the clinic by his mother due to concerns about

his social communication and repetitive behaviors. According to the informant (mother), S.K.

has had delayed speech and language development since infancy. He began speaking single

words at 3 years of age and has not progressed to forming sentences. He avoids eye contact

and rarely responds to his name being called.

S.K. engages in repetitive behaviors such as hand flapping, rocking, and spinning objects. He

becomes fixated on specific objects, particularly the spinning wheels of toy cars, and spends

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hours playing with them in isolation. He shows little interest in interacting with peers and

prefers to play alone. Any changes in his daily routine, such as a different route to school or a

new meal, lead to significant distress and tantrums.

The onset of these symptoms has been insidious, with no clear precipitating factors. The

course has been continuous, with no significant improvement or deterioration over time.

There is no history of head injury, seizures, or other medical conditions that could explain his

symptoms.

Precipitating Factors: Not elicited.

NEGATIVE HISTORY

• No history of head injury.

• No history of seizures.

MEDICAL HISTORY

• Illness: None

• Operation: None

• Accidents: None

• Surgical Problem: None

PAST PSYCHIATRIC HISTORY

• Information of Client’s Past Psychiatric Record: None

• Dates: Not applicable

• Duration: Not applicable

• Symptoms: Not applicable

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• Diagnosis: Not applicable

• Treatment: None

FAMILY HISTORY

o Father: P.K. (alive, no psychiatric history)

o Mother: R.K. (alive, no psychiatric history)

o Sibling: None

• Family Type: Nuclear

• Family Size: 3 members

• Socioeconomic Status: Middle class

• Family Description: Supportive and structured

• History of Psychiatric Illness: None

• History of Other Medical Illness: None

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PERSONAL AND DEVELOPMENTAL HISTORY

1. Parental Attitude Towards Pregnancy: Wanted

2. Mother’s Health During Pregnancy:

o No illness.

o No X-ray exposure.

o No prolonged drug administration.

o No attempted abortion.

3. Nature of Birth:

o Full-term normal delivery.

o No complications.

o Immediate birth cry.

4. Feeding Habits in Early Childhood: Breastfed.

5. Age of Milestones:

o Neck holding: 5 months

o Sitting: 9 months

o Standing: 1.3 years

o Walking: 1.6 years

o First word: 3 years

o Three-word sentence: Not achieved.

o Bowel control: 2.5 years

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o Bladder control: 3 years

6. Developmental Problems: Delayed speech and language development.

7. Neurotic Symptoms in Childhood: None

8. Behavior Problems: Repetitive behaviors (e.g., hand flapping, rocking).

9. Health During Childhood: No significant illnesses or infections

SCHOOLING

• Special Abilities/Disabilities: Fixation on spinning objects.

• Performance in Academics: Poor

• Number of Friends: None

• Relationship with Peers: Poor

• Co-curricular Activities: None

• Hobbies and Interests: Spinning wheels of toy cars.

SOCIAL AND PERSONAL HISTORY

1. Habits:

o Sleep: Normal

o Feeding: Fussy

o Personal Care: Adequate

2. Neurotic Traits: None

3. Behavior Problems: Repetitive behaviors.

4. Play: Prefers solitary play with spinning objects.

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5. Sexual History: Not applicable (child).

PREMORBID PERSONALITY

• Social Relations:

o Family: Limited interaction, prefers solitary activities

o Friends: No friends, prefers solitary play

o Relatives: Limited interaction

• Intellectual Activities:

o Hobbies: Fixation on spinning objects

o Interests: None

o Memory: Good memory for specific topics

o Observation: Good observation skills for objects of interest

o Judgment: Impaired in social situations

• Mood of Client: Generally calm but becomes upset if routine is disrupted

• Character:

o Attitude to Work and Responsibility: Not applicable (child)

o Interpersonal Relationships: Limited interaction, prefers solitary activities

• Fantasy Life: Minimal daydreaming

• Habits:

o Eating: Fussy

o Alcohol Consumption: Not applicable

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o Self-Medication: Not applicable

MENTAL STATUS EXAMINATION (MSE)

General Appearance and Behavior

• Appearance: Looking one’s age.

• Level of Grooming: Normal.

• Level of Cleanliness: Adequate.

• Level of Consciousness: Fully conscious and alert.

• Mode of Entry: Came willingly.

• Cooperativeness: Normal.

• Eye-to-Eye Contact: Poor (avoids eye contact).

• Psychomotor Activity: Normal.

• Empathy: Difficult to establish.

• Quality of Rapport: Poor.

• Gesturing: Normal.

• Posturing: Normal posture.

• Other Movements: Hand flapping observed.

• Other Catatonic Phenomena: None.

Impression: Not Intact (poor eye contact, hand flapping, and difficulty establishing rapport).

Speech

• Initiation: Speaks when spoken to.

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• Reaction Time: Delayed.

• Speed: Slow.

• Output: Minimal.

• Pressure of Speech: Absent.

• Volume: Low.

• Tone: Monotonous.

• Manner: Highly formal.

• Relevance: Fully relevant.

• Stream: Normal.

• Coherence: Fully coherent.

• Others: None.

• Sample of Speech:

o Clinician: “What is your name?”

o Client: “S.K.” (spoken softly after a delay).

Impression: Not Intact (delayed reaction time, minimal output, and monotonous tone).

Thought

• Tempo: Normal.

• Form: Adequate.

• Obsession: None.

• Compulsion: None.

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• Thought Alienation Phenomena: None.

• Thought Commentary: None.

• Thought Contents:

o Idea: Fixation on spinning objects.

o Overvalued Idea: None.

o Delusion: None.

Impression: Intact (no formal thought disorder).

Mood

• Subjective: Not elicited (child is nonverbal).

• Objective: Calm but becomes upset if routine is disrupted.

• Predominant Mood State: Euthymic.

• Other Major Moods: None.

• Range: Restricted.

• Reactivity: Reactive.

• Quality of Mood: Calm.

• Communicability: Poor.

• Lability: None.

• Appropriateness: Appropriate to thought content.

• Congruence: Mood congruent.

• Emotional Expression: Blunted.

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Impression: Intact (mood is congruent with affect).

Perception

• Hallucination: None.

• Illusion: None.

• Depersonalization: None.

• Déjà Vu Phenomena: None.

• Somatic Passivity: None.

• Special: None.

Impression: Intact (no perceptual abnormalities).

Cognitive Functions

• Attention: Normally aroused but easily distracted.

• Digit Forward: 3/5.

• Digit Backward: 2/5.

• Concentration: Sustained with difficulty.

• 100-7 Test: Unable to complete.

• 40-3 Test: Unable to complete.

• 20-1 Test: Unable to complete.

• Months Backwards: Unable to complete.

• Weekdays Backwards: Unable to complete.

Impression: Not Intact (attention and concentration are impaired).

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Orientation

• Time: Approximate time (knows day but not date or month).

• Place: Kind of place (knows he is in a clinic).

• Person: Self and close associates (recognizes himself and family members).

Impression: Partially Intact (oriented to place and person but not fully to time).

Memory

• Immediate: 2/3 objects recalled immediately.

• Recent: Recalls last meal but not visitors.

• Verbal Recall:

o After 5 minutes: 2/3 objects.

o After 10 minutes: 1/3 objects.

• Visual Recall: 2/3 objects recalled.

• Remote: Recalls personal events but not impersonal events.

Impression: Not Intact (memory is impaired).

Intelligence

• Comprehension: Understands simple commands.

• Vocabulary: Limited (can name common objects).

• Arithmetic Ability: Unable to perform mental arithmetic.

• General Fund of Information:

o Literate: Knows his name and basic objects.

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o Current Events: Unaware of current events.

Impression: Not Intact (intelligence is below average).

Abstraction

• Interpretation of Proverbs: Unable to interpret.

• Similarities Between Paired Objects: Concrete.

o “Apple and orange” interpreted as “Both are fruits.”

• Dissimilarities Between Paired Objects: Unable to identify.

Impression: Not Intact (abstract thinking is impaired).

Judgment

• Personal: Impaired (unable to plan or complete tasks).

• Social: Impaired (does not understand social norms).

• Test: Impaired (unable to predict consequences of actions).

Impression: Not Intact (judgment is impaired)

DIAGNOSTIC FORMULATION

• Major Diagnosis: Autism Spectrum Disorder (F84.0, ICD-10)

• Differential Diagnosis:

o Intellectual Disability (F70-F79, ICD-10)

o Language Disorder (F80.9, ICD-10)

• Associated Diagnoses: None

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PSYCHOPATHOLOGY

S.K., a 6-year-old male, was referred by his school due to concerns about delayed speech,

poor eye contact, repetitive behaviors, and difficulty interacting with peers. His mother, the

primary informant, reports that his symptoms have been present since early childhood, with

an insidious onset and a continuous course. He exhibits fixation on spinning objects, resists

changes in routine, and has minimal verbal communication. His developmental history

reveals delayed speech and language milestones, though motor milestones were achieved

within the normal range. There is no history of medical or psychiatric illness in the family.

Mental status examination highlights poor eye contact, minimal speech output, and impaired

social and cognitive functioning. Based on clinical observations and history, a provisional

diagnosis of Autism Spectrum Disorder (F84.0, ICD-10) has been considered, with

differential diagnoses including Intellectual Disability and Language Disorder. Management

will focus on behavioral interventions such as Applied Behavior Analysis (ABA), speech

therapy, and occupational therapy, alongside family counseling and school accommodations.

PSYCHOTHERAPY AND MANAGEMENT

• Medications: None (behavioral interventions preferred).

• Therapy: Applied Behavior Analysis (ABA), Speech Therapy, Occupational Therapy

• Social Support: School accommodations, family counseling

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CASE HISTORY 2

SOCIO-DEMOGRAPHIC DATA

• Name: A.R.

• Age: 8 years

• Date of Birth: 15/03/2016

• Sex: Female

• Education: 2nd Standard

• Residence: Flat No. 45, Green Valley Apartments, Indiranagar, Bangalore

• Family Structure: Nuclear family (parents and child)

• Mother Tongue: Kannada

• Religion: Hindu

REFERRAL DETAILS

• Referral Source: Self

• Informant Details:

o Name: S.R. (Mother)

o Relationship with Client: Mother

o Acquaintance: Lifelong

o Adequacy: Good

o Reliability: Good

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PRESENTING COMPLAINTS

• According to Informant (Mother):

o No focus on tasks.

o Too many mistakes in any task.

o Easily distracted.

o Not completing tasks.

o Interrupts others while talking.

• According to Client: Not elicited (child is nonverbal).

HISTORY OF PRESENTING ILLNESS (HOPI)

• Duration: Since childhood

• Mode of Onset: Insidious

• Course: Continuous

Body of HOPI:

A.R., an 8-year-old female, has been brought to the clinic by her mother due to concerns

about her attention and behavior. According to the informant (mother), A.R. has had

persistent difficulties with focus and task completion since early childhood. She is easily

distracted by external stimuli, such as noises or movements in her environment, and often

makes careless mistakes in her schoolwork and daily activities. Despite repeated reminders,

she struggles to complete tasks and frequently leaves them unfinished.

A.R. also exhibits impulsive behaviors, such as interrupting others during conversations and

having difficulty waiting her turn during games or group activities. These behaviors are

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observed both at home and in school, where her teachers have reported similar concerns. Her

academic performance has been poor, and she has limited peer interactions, often preferring

to play alone.

The onset of these symptoms has been insidious, with no clear precipitating factors. The

course has been continuous, with no significant improvement or deterioration over time.

There is no history of head injury, seizures, or other medical conditions that could explain her

symptoms.

NEGATIVE HISTORY

• No history of head injury.

• No history of seizures.

MEDICAL HISTORY

• Illness: None

• Operation: None

• Accidents: None

• Surgical Problem: None

PAST PSYCHIATRIC HISTORY

• Information of Client’s Past Psychiatric Record: None

• Dates: Not applicable

• Duration: Not applicable

• Symptoms: Not applicable

• Diagnosis: Not applicable

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• Treatment: None

FAMILY HISTORY

• Family Type: Nuclear

• Family Size: 3 members

• Socioeconomic Status: Middle class

• Family Description: Supportive and structured

• History of Psychiatric Illness: None

• History of Other Medical Illness: None

PERSONAL AND DEVELOPMENTAL HISTORY

1. Parental Attitude Towards Pregnancy: Wanted

2. Mother’s Health During Pregnancy:

o No illness.

o No X-ray exposure.

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o No prolonged drug administration.

o No attempted abortion.

3. Nature of Birth:

o Full-term normal delivery.

o No complications.

o Immediate birth cry.

4. Feeding Habits in Early Childhood: Breastfed.

5. Age of Milestones:

o Neck holding: 4 months

o Sitting: 8 months

o Standing: 1 year

o Walking: 1.2 years

o First word: 11 months

o Three-word sentence: 1.4 years

o Bowel control: 2 years

o Bladder control: 2 years

6. Developmental Problems: None

7. Neurotic Symptoms in Childhood: None

8. Behavior Problems: None

9. Health During Childhood: No significant illnesses or infections

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SCHOOLING

• Special Abilities/Disabilities: None

• Performance in Academics: Poor

• Number of Friends: 2

• Relationship with Peers: Poor

• Co-curricular Activities: None

• Hobbies and Interests: None

SOCIAL AND PERSONAL HISTORY

1. Habits:

o Sleep: Normal

o Feeding: Fussy

o Personal Care: Adequate

2. Neurotic Traits: None

3. Behavior Problems: None

4. Play: Prefers solitary play.

5. Sexual History: Not applicable (child).

PREMORBID PERSONALITY

• Social Relations:

o Family: Limited interaction, prefers solitary activities

o Friends: Minimal interaction, prefers solitary play

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o Relatives: Limited interaction

• Intellectual Activities:

o Hobbies: None

o Interests: None

o Memory: Good memory for specific topics

o Observation: Good observation skills for objects of interest

o Judgment: Impaired in social situations

• Mood of Client: Generally calm but becomes upset if routine is disrupted

• Character:

o Attitude to Work and Responsibility: Not applicable (child)

o Interpersonal Relationships: Limited interaction, prefers solitary activities

• Fantasy Life: Minimal daydreaming

• Habits:

o Eating: Fussy

o Alcohol Consumption: Not applicable

o Self-Medication: Not applicable

MENTAL STATUS EXAMINATION (MSE)

General Appearance and Behavior

• Appearance: Looking one’s age.

• Level of Grooming: Normal.

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• Level of Cleanliness: Adequate.

• Level of Consciousness: Fully conscious and alert.

• Mode of Entry: Came willingly.

• Cooperativeness: Normal.

• Eye-to-Eye Contact: Maintained but inconsistent.

• Psychomotor Activity: Increased restlessness (fidgety, tapping feet, and playing with

hands).

• Empathy: Spontaneous.

• Quality of Rapport: Good.

• Gesturing: Normal.

• Posturing: Normal posture.

• Other Movements: None (no mannerisms, stereotypes, tremors, EPS, AIMS, or

perseveration).

• Other Catatonic Phenomena: None (no automatic obedience, negativism, waxy

flexibility, echopraxia, or echolalia).

Speech

• Initiation: Speaks when spoken to.

• Reaction Time: Normal.

• Speed: Rapid.

• Output: Increased.

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• Pressure of Speech: Present (talks quickly and interrupts frequently).

• Volume: Normal.

• Tone: Normal variation.

• Manner: Inappropriately familiar.

• Relevance: Sometimes off target.

• Stream: Tangential (jumps from one topic to another).

• Coherence: Fully coherent.

• Others: None (no rhyming, punning, echolalia, perseveration, or neologism).

• Sample of Speech:

o Clinician: “Can you tell me about your school?”

o Client: “School is okay… I like playing with my friends during break, but

sometimes I forget to do my homework. My teacher gets mad at me because I

don’t finish my work. Oh, and yesterday I saw a dog outside the school gate—

it was so cute! Do you like dogs? I also like drawing, but I don’t have time

because I have to study… but I don’t like studying much.”

Impression: Speech not Intact

Thought

• Tempo: Racy thoughts.

• Form: Adequate.

• Obsession: None.

• Compulsion: None.

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• Thought Alienation Phenomena: None (no thought insertion, withdrawal, or

broadcast).

• Thought Commentary: None.

• Thought Contents:

o Idea: Difficulty focusing on tasks.

o Overvalued Idea: None.

o Delusion: None.

o Example: “I try to do my homework, but I keep thinking about other things,

like playing or what’s for dinner.”

Impression: thought Intact

Mood

• Subjective: “I

• feel fine, but sometimes I get frustrated when I can’t finish my work.”

• Objective: Bright and cheerful.

• Predominant Mood State: Euthymic.

• Other Major Moods: None.

• Range: Reactive.

• Reactivity: Reactive.

• Quality of Mood: Bright and cheerful.

• Communicability: Good.

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• Lability: None.

• Appropriateness: Appropriate to thought content.

• Congruence: Mood congruent.

• Emotional Expression: Normal.

Impression: mood is congruent with affect

Perception

• Hallucination: None.

• Illusion: None.

• Depersonalization: None.

• Déjà Vu Phenomena: None.

• Somatic Passivity: None.

• Special: None (no made acts).

Impression: perception Intact

Cognitive Functions

• Attention: Normally aroused but easily distracted.

• Digit Forward: 5/5.

• Digit Backward: 3/5.

• Concentration: Sustained with difficulty.

• 100-7 Test: 93, 86, 79, 72, 65 (completed with occasional prompts).

• 40-3 Test: 37, 34, 31, 28, 25 (completed with occasional prompts).

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• 20-1 Test: 19, 18, 17, 16, 15 (completed with occasional prompts).

• Months Backwards: Completed with difficulty.

• Weekdays Backwards: Completed with difficulty.

Impression: Attention and concentration Not Intact

Orientation

• Time: Approximate time (knows day, date, month, and year).

• Place: Kind of place (knows she is in a clinic).

• Person: Self and close associates (recognizes herself and family members).

Impression: orientation to time, place, and person intact

Memory

• Immediate: 3/3 objects recalled immediately.

• Recent: Recalls last meal and visitors.

• Verbal Recall:

o After 5 minutes: 3/3 objects.

o After 10 minutes: 3/3 objects.

• Visual Recall: 3/3 objects recalled.

• Remote: Recalls personal and impersonal events accurately.

Impression: memory is Intact

Intelligence

• Comprehension: Understands simple and complex commands.

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• Vocabulary: Good (can name common and uncommon objects).

• Arithmetic Ability: Adequate (can perform mental arithmetic).

• General Fund of Information:

o Literate: Knows the name of the Prime Minister, 5 rivers, cities, states, and

capitals of countries.

o Current Events: Aware of major current events.

Impression: intelligence is average

Abstraction

• Interpretation of Proverbs: Concrete.

o “A stitch in time saves nine” interpreted as “Sewing saves clothes.”

• Similarities Between Paired Objects: Concrete.

o “Apple and orange” interpreted as “Both are fruits.”

• Dissimilarities Between Paired Objects: Concrete.

o “Book and TV” interpreted as “One is for reading, the other is for watching.”

Impression: abstract thinking is concrete

Judgment

• Personal: Impaired (struggles to plan and complete tasks).

• Social: Intact (understands social norms).

• Test: Impaired (predicts difficulty in completing tasks due to distractibility).

Impression: judgment not intact

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DIAGNOSTIC FORMULATION

• Major Diagnosis: Attention-Deficit/Hyperactivity Disorder, Predominantly

Inattentive Presentation (F90.0, ICD-10)

• Differential Diagnosis:

o Autism Spectrum Disorder (F84.0, ICD-10)

o Specific Learning Disorder (F81.9, ICD-10)

• Associated Diagnoses: None

PSYCHOPATHOLOGY

A.R. presents with significant attentional difficulties, impulsivity, and distractibility,

consistent with Attention-Deficit/Hyperactivity Disorder (ADHD), Predominantly Inattentive

Presentation. Her symptoms, including an inability to sustain attention, frequent careless

mistakes, difficulty completing tasks, and excessive restlessness, have been persistent since

early childhood and are observed across multiple settings, impacting her academic

performance and social interactions. Her speech is tangential, with rapid output and frequent

interruptions, further indicating impaired self-regulation. Cognitive assessment reveals

deficits in sustained attention and concentration, along with impaired judgment in task

completion. While her mood remains euthymic and her perception intact, her concrete

PSYCHOTHERAPY AND MANAGEMENT

• Medications: Stimulants (e.g., Methylphenidate)

• Therapy: Behavioral Therapy, Parent Training

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• Social Support: School accommodations, family counselling

thinking and impaired executive functioning suggest challenges in higher-order cognitive

processing, reinforcing the diagnosis.

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CASE HISTORY 3

SOCIO-DEMOGRAPHIC DATA

• Name: RS

• Age: 10 years

• Date of Birth: 12th March 2013

• Sex: Male • Education: 5th Grade

• Residence: Urban, Bengaluru, Karnataka

• Family Structure: Nuclear family (Father, Mother, and Rohan)

• Mother Tongue: Hindi • Religion: Hindu

REFERRAL DETAILS

• Referral Source: School Counselor

• Reason for Referral: RS was referred by his school counselor due to persistent anxiety,

difficulty concentrating in class, and frequent complaints of stomach aches before exams.

INFORMANT DETAILS

• Name: Mrs. AS (Mother)

• Relationship with Client: Mother

• Acquaintance: Lives with the client

• Adequacy: Adequate (provided detailed information)

• Reliability: Reliable (consistent and corroborated information)

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PRESENTING COMPLAINTS

• According to Informant (Mother):

o RS has been excessively worried about school performance for the past 6 months.

o He frequently complains of stomach aches and headaches, especially before exams.

o He avoids participating in group activities and prefers to stay alone.

o He has difficulty falling asleep and often wakes up in the middle of the night.

• According to Client (RS):

o "I feel scared before exams and think I will fail."

o "My stomach hurts when I think about school."

o "I don’t like playing with others because I feel they will laugh at me."

HISTORY OF PRESENTING ILLNESS (HOPI)

• Duration: 6 months • Mode of Onset: Insidious (gradual increase in symptoms)

• Course: Fluctuating (worsens during exam periods)

• Body of HOPI:

RS, a 10-year-old boy, has been experiencing anxiety-related symptoms for the past six

months. His symptoms emerged gradually following a poor performance on a math test, after

which he became excessively concerned about his academic abilities. His mother noted an

increase in self-doubt, with RS frequently voicing fears of failure and a lack of confidence in

his skills. Alongside these worries, he started experiencing physical symptoms such as

stomach aches and headaches, particularly in the mornings before school or on exam days.

His mother observed that he would often complain of stomach pain and resist going to

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school. As his anxiety persisted, it began affecting his daily life. He started avoiding peer

interactions, choosing to stay alone during recess, fearing that his classmates might judge him

for his academic struggles. Additionally, he exhibited a heightened need for reassurance from

his parents, frequently seeking validation about his performance and expressing concerns

about their approval. His attachment to his parents increased, especially at night, where he

preferred to stay close to them at bedtime. Sleep disturbances also became evident, with

difficulty falling asleep and frequent nighttime awakenings, often accompanied by crying or

calling out for his mother. He described persistent worries about school and exams, which

interfered with his ability to rest. His mother also noted occasional nightmares, though he had

trouble recalling their content. The severity of his symptoms has varied over time, with

noticeable exacerbations during exam periods. In the past two months, leading up to his mid-

term exams, his anxiety has intensified, leading to a rise in physical complaints and

occasional school refusal, citing illness as the reason.

Precipitating Factors:

• Academic pressure from school and high expectations from parents.

• Fear of failure and criticism from teachers and peers.

• Lack of coping mechanisms to deal with stress.

Maintaining Factors:

• Avoidance behaviors (e.g., skipping school, avoiding social interactions).

• Excessive reassurance-seeking from parents.

• Lack of open communication about his fears and worries.

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NEGATIVE HISTORY

• No history of substance abuse, self-harm, or suicidal ideation.

• No history of trauma or abuse.

MEDICAL HISTORY

• Illness: None significant.

• Operation: None.

• Accidents: None.

• Surgical Problem: None.

PAST PSYCHIATRIC HISTORY

• No previous psychiatric consultations or treatments.

FAMILY HISTORY

o Father: 38 years, Engineer, no psychiatric history.

o Mother: 35 years, Homemaker, no psychiatric history.

o Maternal Grandfather: History of hypertension.

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o Paternal Grandmother: History of diabetes.

• Family Type: Nuclear

• Family Size: 3 members

• Socio-Economic Status: Middle class

• Family Description: Supportive but academically demanding.

• History of Psychiatric Illness: None.

• History of Other Medical Illness: Hypertension and diabetes in grandparents.

PERSONAL AND DEVELOPMENTAL HISTORY

1. Parental Attitude Towards Pregnancy: Wanted.

2. Mother’s Health During Pregnancy:

o No significant illness, X-ray exposure, or drug administration.

o No attempted abortion.

3. Nature of Birth: Full-term normal delivery.

4. Feeding Habits in Early Childhood: Breastfed for 6 months.

5. Age of Developmental Milestones:

o Neck holding: 3 months

o Tooth eruption: 7 months

o Sitting: 8 months

o Standing: 10 months

o Walking: 13 months

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o First word: 12 months

o Three-word sentence: 24 months

o Bowel and bladder control: 2.5 years

6. Developmental Problems: None.

7. Neurotic Symptoms in Childhood: Temper tantrums at age 3-4 years.

8. Behavior Problems: Nail-biting observed since age 6.

HEALTH DURING CHILDHOOD

• No significant childhood infections or illnesses.

• No history of infantile convulsions.

SCHOOLING

• Special Abilities/Disabilities: Good at drawing but struggles with math.

• Performance in Academics: Average, but declining due to anxiety.

• Number of Friends: Few (2-3 close friends).

• Relationship with Peers: Avoids group activities.

• Co-curricular Activities: Enjoys drawing and painting.

• Hobbies and Interests: Drawing and watching cartoons.

SOCIAL AND PERSONAL HISTORY

1. Habits:

o Sleep: Difficulty falling asleep, wakes up at night. o Feeding: Fussy eater.

o Personal Care: Adequate.

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2. Neurotic Traits: Nail-biting, fear of darkness.

3. Behavior Problems: None significant.

4. Play: Prefers individual play.

5. Sexual History: Not applicable.

EDUCATIONAL HISTORY

• Qualified Up To: 5th Grade.

• Educated At: School.

• Started Reading At: 5 years.

• Educational Problems: Poor progress in math, difficulty concentrating.

• Failures: None.

• Attention/Concentration: Difficulty focusing, especially in math.

TEMPERAMENTAL CHARACTERISTICS

• Activity: Moderate

• Rhythmicity: Irregular sleep patterns

• Approach-Withdrawal: Withdraws from new situations

• Adaptability: Slow to adapt

• Mood: Anxious

• Intensity of Reaction: High

• Threshold of Responsiveness: Low

• Attention-Span: Short

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• Persistence: Low

• Distractibility: High

PATTERNS OF PARENTAL FUNCTIONING

• Permissiveness/Rigidity: Moderately strict.

• Consistency/Inconsistency: Consistent.

• Strictness of Discipline: High academic expectations.

• Approval of Interests: Encourages drawing but prioritizes academics.

• Protectiveness: Overprotective.

• Toleration of Deviance: Low.

• Expectations from the Child: High academic performance.

• Reactions Towards the Illness: Concerned but initially dismissive of anxiety symptoms.

SPECIAL ENVIRONMENTAL CIRCUMSTANCES

• High academic pressure from school and parents.

MENTAL STATUS EXAMINATION (MSE)

General Appearance and Behavior:

• Appearance: RS looks his age (10 years old). He is dressed in a clean school uniform,

indicating adequate grooming.

• Level of Grooming: Normal.

• Level of Cleanliness: Adequate.

• Level of Consciousness: Fully conscious and alert.

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• Mode of Entry: Came willingly with his mother.

• Cooperativeness: Cooperative but appeared anxious and fidgety during the interview.

• Eye Contact: Maintained intermittently but would often look down when discussing his

worries.

• Psychomotor Activity: Normal, though he occasionally tapped his feet or played with his

fingers.

• Empathy: Spontaneous. He expressed concern for his mother’s feelings.

• Quality of Rapport: Good. He responded openly to questions but hesitated when discussing

his fears.

• Gesturing: Normal.

• Posturing: Normal posture.

• Other Movements: Occasional nail-biting observed.

Speech:

• Initiation: Speaks when spoken to.

• Reaction Time: Normal.

• Speed: Normal, though slightly hesitant when discussing anxiety-provoking topics.

• Output: Normal.

• Pressure of Speech: Absent.

• Volume: Soft but audible.

• Tone: Normal variation.

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• Manner: Normal.

• Relevance: Fully relevant.

• Stream: Normal.

• Coherence: Fully coherent.

• Sample of Speech: When asked about his fears, Rohan said, “I feel scared before exams. I

think I will fail, and everyone will laugh at me.”

Thought:

• Tempo: Normal.

• Form: Adequate.

• Content: Preoccupied with fears of academic failure and social judgment.

• Examples: “I can’t do math; I’m not smart enough,” and “What if I fail again?” Mood:

• Subjective: “I feel scared and worried most of the time.”

• Objective: Anxious, as evidenced by his restlessness and frequent expressions of worry.

Perception: • No hallucinations or illusions were reported.

Cognitive Functions:

• Attention: Normally aroused but easily distracted by external noises.

• Concentration: Sustained with difficulty. He struggled with the 100-7 task, making errors

after the third subtraction.

• Orientation: Fully oriented to time, place, and person.

• Memory: o Immediate: Recalled 3/3 objects immediately.

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o Recent: Recalled what he had for breakfast.

o Remote: Recalled his last birthday celebration.

• Intelligence: Average for his age.

• Abstraction: Concrete. When asked to interpret the proverb “A stitch in time saves nine,” he

said, “If you fix something early, it won’t get worse.”

• Judgment: Intact. He understood the consequences of skipping school.

• Insight: Partial. He acknowledged feeling unwell but attributed it to “being weak” rather

than anxiety.

DIAGNOSTIC FORMULATION

• Major Diagnosis: Generalized Anxiety Disorder (ICD-10: F41.1).

• Differential Diagnosis: Adjustment Disorder with Anxiety (ICD-10: F43.22).

• Associated Diagnoses: None.

PSYCHOTHERAPY AND MANAGEMENT

1. Psychotherapy: Cognitive Behavioral Therapy (CBT) to address negative thought patterns

and develop coping strategies. o Relaxation techniques (e.g., deep breathing, progressive

muscle relaxation).

2. Parental Counseling: Educate parents about reducing academic pressure and fostering a

supportive environment.

3. School Intervention: Collaborate with teachers to provide academic support and reduce

performance-related stress.

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4. Pharmacotherapy: Consider SSRIs (e.g., Sertraline) if symptoms persist despite therapy.

PSYCHOPATHOLOGY

RS exhibits excessive academic anxiety with cognitive distortions (fear of failure, low self

efficacy), somatic symptoms (stomach aches, headaches), social withdrawal, and sleep

disturbances. His inhibited temperament, parental pressure, and avoidance behaviors

reinforce the anxiety. The diagnosis aligns with Generalized Anxiety Disorder (GAD, ICD

10: F41.1). CBT, parental counseling, and school-based support are key interventions.

Prognosis:

Good with early intervention, family support, and a structured therapeutic approach.

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CASE HISTORY 4

SOCIO-DEMOGRAPHIC DATA

• Name: V.P.

• Age: 12 years

• Date of Birth: 20/07/2011

• Sex: Male

• Education: 6th Standard

• Residence: No. 78, Malleshwaram, Bangalore, Karnataka

• Family Structure: Nuclear family (parents and child)

• Mother Tongue: Kannada

• Religion: Hindu

REFERRAL DETAILS

• Referral Source: School

• Informant Details:

o Name: R.P. (Mother)

o Relationship with Client: Mother

o Acquaintance: Lifelong

o Adequacy: Good

o Reliability: Good

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PRESENTING COMPLAINTS

• According to Informant (Mother):

o Frequent lying.

o Stealing money from home and school.

o Bullying peers at school.

o Physical fights with siblings and classmates.

o Defiant behavior at home and school.

o Skipping school frequently.

• According to Client: “I don’t like school. My teachers and parents are always

scolding me for no reason.”

HISTORY OF PRESENTING ILLNESS (HOPI)

• Duration: Since 2 years

• Mode of Onset: Gradual

• Course: Progressive

Body of HOPI:

V.P., a 12-year-old male, has been brought to the clinic by his mother due to concerns about

his aggressive and defiant behavior. According to the informant (mother), V.P. has been

exhibiting problematic behaviors for the past two years. He frequently lies to his parents and

teachers, often to cover up his misdeeds. He has been caught stealing money from his

mother’s purse and from his classmates’ bags at school.

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V.P. has been involved in multiple physical fights with his younger sibling and peers at

school. He bullies younger children, often taking their belongings or threatening them. At

home, he is defiant and refuses to follow rules or complete chores. He has been skipping

school frequently, often spending time with older peers in the neighborhood.

The onset of these behaviors has been gradual, starting around the age of 10. The course has

been progressive, with the behaviors becoming more frequent and severe over time. There is

no history of head injury, seizures, or other medical conditions that could explain his

symptoms.

Precipitating Factors: Not elicited.

NEGATIVE HISTORY

• No history of head injury.

• No history of seizures.

MEDICAL HISTORY

• Illness: None

• Operation: None

• Accidents: None

• Surgical Problem: None

PAST PSYCHIATRIC HISTORY

• Information of Client’s Past Psychiatric Record: None

• Dates: Not applicable

• Duration: Not applicable

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• Symptoms: Not applicable

• Diagnosis: Not applicable

• Treatment: None

FAMILY HISTORY

o Father: S.P. (alive, no psychiatric history)

o Mother: R.P. (alive, no psychiatric history)

o Sibling: Younger sister (8 years old)

• Family Type: Nuclear

• Family Size: 4 members

• Socioeconomic Status: Middle class

• Family Description: Supportive but strained due to V.P.’s behavior

• History of Psychiatric Illness: None

• History of Other Medical Illness: None

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PERSONAL AND DEVELOPMENTAL HISTORY

1. Parental Attitude Towards Pregnancy: Wanted

2. Mother’s Health During Pregnancy:

o No illness.

o No X-ray exposure.

o No prolonged drug administration.

o No attempted abortion.

3. Nature of Birth:

o Full-term normal delivery.

o No complications.

o Immediate birth cry.

4. Feeding Habits in Early Childhood: Breastfed.

5. Age of Milestones:

o Neck holding: 4 months

o Sitting: 8 months

o Standing: 1 year

o Walking: 1.2 years

o First word: 11 months

o Three-word sentence: 1.4 years

o Bowel control: 2 years

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o Bladder control: 2 years

6. Developmental Problems: None

7. Neurotic Symptoms in Childhood: None

8. Behavior Problems: Temper tantrums during early childhood.

9. Health During Childhood: No significant illnesses or infections

SCHOOLING

• Special Abilities/Disabilities: None

• Performance in Academics: Poor

• Number of Friends: Few (older peers in the neighborhood)

• Relationship with Peers: Poor (bullies younger children)

• Co-curricular Activities: None

• Hobbies and Interests: Playing video games, spending time with older peers

SOCIAL AND PERSONAL HISTORY

1. Habits:

o Sleep: Normal

o Feeding: Normal

o Personal Care: Adequate

2. Neurotic Traits: None

3. Behavior Problems: Frequent lying, stealing, and physical aggression.

4. Play: Prefers playing with older peers.

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5. Sexual History: Not applicable (child).

PREMORBID PERSONALITY

• Social Relations:

o Family: Strained due to defiant behavior

o Friends: Limited interaction, prefers older peers

o Relatives: Limited interaction

• Intellectual Activities:

o Hobbies: Playing video games

o Interests: None

o Memory: Good memory for specific topics

o Observation: Good observation skills for objects of interest

o Judgment: Impaired in social situations

• Mood of Client: Generally irritable but becomes calm when playing video games

• Character:

o Attitude to Work and Responsibility: Not applicable (child)

o Interpersonal Relationships: Limited interaction, prefers solitary activities

• Fantasy Life: Minimal daydreaming

• Habits:

o Eating: Normal

o Alcohol Consumption: Not applicable

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o Self-Medication: Not applicable

MENTAL STATUS EXAMINATION (MSE)

General Appearance and Behavior

• Appearance: Looking one’s age.

• Level of Grooming: Normal.

• Level of Cleanliness: Adequate.

• Level of Consciousness: Fully conscious and alert.

• Mode of Entry: Came willingly.

• Cooperativeness: Normal.

• Eye-to-Eye Contact: Maintained but inconsistent.

• Psychomotor Activity: Normal.

• Empathy: Difficult to establish.

• Quality of Rapport: Poor.

• Gesturing: Normal.

• Posturing: Normal posture.

• Other Movements: None (no mannerisms, stereotypes, tremors, EPS, AIMS, or

perseveration).

• Other Catatonic Phenomena: None.

Impression: Intact (no significant abnormalities in general behavior).

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Speech

• Initiation: Speaks when spoken to.

• Reaction Time: Normal.

• Speed: Normal.

• Output: Normal.

• Pressure of Speech: Absent.

• Volume: Normal.

• Tone: Normal variation.

• Manner: Inappropriately familiar.

• Relevance: Fully relevant.

• Stream: Normal.

• Coherence: Fully coherent.

• Others: None.

• Sample of Speech:

o Clinician: “Why do you skip school?”

o Client: “School is boring. My teachers are always shouting at me for no

reason. I’d rather play with my friends.”

Impression: Intact (speech is coherent and relevant).

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Thought

• Tempo: Normal.

• Form: Adequate.

• Obsession: None.

• Compulsion: None.

• Thought Alienation Phenomena: None.

• Thought Commentary: None.

• Thought Contents:

o Idea: Disinterest in school and authority figures.

o Overvalued Idea: None.

o Delusion: None.

Impression: Intact (no formal thought disorder).

Mood

• Subjective: “I feel fine, but I get angry when people tell me what to do.”

• Objective: Irritable.

• Predominant Mood State: Irritable.

• Other Major Moods: None.

• Range: Restricted.

• Reactivity: Reactive.

• Quality of Mood: Irritable.

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• Communicability: Good.

• Lability: None.

• Appropriateness: Appropriate to thought content.

• Congruence: Mood congruent.

• Emotional Expression: Normal.

Impression: Intact (mood is congruent with affect).

Perception

• Hallucination: None.

• Illusion: None.

• Depersonalization: None.

• Déjà Vu Phenomena: None.

• Somatic Passivity: None.

• Special: None.

Impression: Intact (no perceptual abnormalities).

Cognitive Functions

• Attention: Normally aroused.

• Digit Forward: 5/5.

• Digit Backward: 4/5.

• Concentration: Normally sustained.

• 100-7 Test: 93, 86, 79, 72, 65 (completed without difficulty).

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• 40-3 Test: 37, 34, 31, 28, 25 (completed without difficulty).

• 20-1 Test: 19, 18, 17, 16, 15 (completed without difficulty).

• Months Backwards: Completed without difficulty.

• Weekdays Backwards: Completed without difficulty.

Impression: Intact (cognitive functions are preserved).

Orientation

• Time: Approximate time (knows day, date, month, and year).

• Place: Kind of place (knows he is in a clinic).

• Person: Self and close associates (recognizes himself and family members).

Impression: Intact (oriented to time, place, and person).

Memory

• Immediate: 3/3 objects recalled immediately.

• Recent: Recalls last meal and visitors.

• Verbal Recall:

o After 5 minutes: 3/3 objects.

o After 10 minutes: 3/3 objects.

• Visual Recall: 3/3 objects recalled.

• Remote: Recalls personal and impersonal events accurately.

Impression: Intact (memory is preserved).

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Intelligence

• Comprehension: Understands simple and complex commands.

• Vocabulary: Good (can name common and uncommon objects).

• Arithmetic Ability: Adequate (can perform mental arithmetic).

• General Fund of Information:

o Literate: Knows the name of the Prime Minister, 5 rivers, cities, states, and

capitals of countries.

o Current Events: Aware of major current events.

Impression: Intact (intelligence is average).

Abstraction

• Interpretation of Proverbs: Concrete.

o “A stitch in time saves nine” interpreted as “Sewing saves clothes.”

• Similarities Between Paired Objects: Concrete.

o “Apple and orange” interpreted as “Both are fruits.”

• Dissimilarities Between Paired Objects: Concrete.

o “Book and TV” interpreted as “One is for reading, the other is for watching.”

Impression: Not Intact (abstract thinking is concrete).

Judgment

• Personal: Impaired (unable to plan or complete tasks).

• Social: Impaired (does not understand social norms).

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• Test: Impaired (unable to predict consequences of actions).

Impression: Not Intact (judgment is impaired).

DIAGNOSTIC FORMULATION

• Major Diagnosis: Conduct Disorder, Childhood-Onset Type (F91.1, ICD-10)

• Differential Diagnosis:

o Oppositional Defiant Disorder (F91.3, ICD-10)

o Attention-Deficit/Hyperactivity Disorder (F90.0, ICD-10)

• Associated Diagnoses: None

PSYCHOPATHOLOGY

V.P., a 12-year-old boy, presents with persistent patterns of deceitful, aggressive, and defiant

behaviors that have progressively worsened over the past two years. His conduct includes

frequent lying, stealing, bullying, physical aggression, and school truancy, indicating

significant behavioral dysregulation. He exhibits poor social relationships, preferring the

company of older peers, and struggles with authority figures, often reacting with irritability

and defiance. His academic performance is poor, and he lacks engagement in co-curricular

activities. While cognitive functions remain intact, his judgment is impaired, and his thinking

is concrete. The clinical presentation is consistent with Conduct Disorder (Childhood-Onset

Type), with differential considerations including Oppositional Defiant Disorder and ADHD.

His strained family dynamics and possible environmental influences, such as peer group

associations, may contribute to his behavioral problems, necessitating behavioral

interventions and family therapy.

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PSYCHOTHERAPY AND MANAGEMENT

• Medications: None (behavioral interventions preferred).

• Therapy: Cognitive Behavioral Therapy (CBT), Family Therapy

• Social Support: School counseling, community support programs

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CASE HISTORY 5

SOCIO-DEMOGRAPHIC DATA

• Name: R.K.

• Age: 10 years

• Date of Birth: 05/09/2013

• Sex: Male

• Education: 3rd Standard (special education)

• Residence: No. 12, Jayanagar, Bangalore, Karnataka

• Family Structure: Nuclear family (parents and child)

• Mother Tongue: Kannada

• Religion: Hindu

REFERRAL DETAILS

• Referral Source: School

• Informant Details:

o Name: L.K. (Mother)

o Relationship with Client: Mother

o Acquaintance: Lifelong

o Adequacy: Good

o Reliability: Good

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PRESENTING COMPLAINTS

• According to Informant (Mother):

o Delayed speech and language development.

o Difficulty understanding instructions.

o Poor academic performance.

o Limited social interactions.

o Difficulty performing daily activities independently (e.g., dressing, eating).

• According to Client: Not elicited (child has limited verbal abilities).

HISTORY OF PRESENTING ILLNESS (HOPI)

• Duration: Since early childhood

• Mode of Onset: Insidious

• Course: Continuous

Body of HOPI:

R.K., a 10-year-old male, has been brought to the clinic by his mother due to concerns about

his intellectual and adaptive functioning. According to the informant (mother), R.K. has had

delayed speech and language development since infancy. He began speaking single words at

4 years of age and has not progressed to forming complete sentences. He struggles to

understand complex instructions and often requires repeated explanations for simple tasks.

R.K. attends a special education school where his academic performance is significantly

below that of his peers. He has difficulty with basic arithmetic, reading, and writing. His

social interactions are limited, and he prefers to play alone or with younger children. He

requires assistance with daily activities such as dressing, eating, and personal hygiene.
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The onset of these symptoms has been insidious, with no clear precipitating factors. The

course has been continuous, with no significant improvement or deterioration over time.

There is no history of head injury, seizures, or other medical conditions that could explain his

symptoms.

Precipitating Factors: Not elicited.

NEGATIVE HISTORY

• No history of head injury.

• No history of seizures.

MEDICAL HISTORY

• Illness: None

• Operation: None

• Accidents: None

• Surgical Problem: None

PAST PSYCHIATRIC HISTORY

• Information of Client’s Past Psychiatric Record: None

• Dates: Not applicable

• Duration: Not applicable

• Symptoms: Not applicable

• Diagnosis: Not applicable

• Treatment: None

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FAMILY HISTORY

o Father: S.K. (alive, no psychiatric history)

o Mother: L.K. (alive, no psychiatric history)

o Sibling: None

• Family Type: Nuclear

• Family Size: 3 members

• Socioeconomic Status: Middle class

• Family Description: Supportive and structured

• History of Psychiatric Illness: None

• History of Other Medical Illness: None

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PERSONAL AND DEVELOPMENTAL HISTORY

1. Parental Attitude Towards Pregnancy: Wanted

2. Mother’s Health During Pregnancy:

o No illness.

o No X-ray exposure.

o No prolonged drug administration.

o No attempted abortion.

3. Nature of Birth:

o Full-term normal delivery.

o No complications.

o Immediate birth cry.

4. Feeding Habits in Early Childhood: Breastfed.

5. Age of Milestones:

o Neck holding: 6 months

o Sitting: 10 months

o Standing: 1.5 years

o Walking: 2 years

o First word: 4 years

o Three-word sentence: Not achieved.

o Bowel control: 3 years

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o Bladder control: 4 years

6. Developmental Problems: Delayed speech and language development.

7. Neurotic Symptoms in Childhood: None

8. Behavior Problems: None

9. Health During Childhood: No significant illnesses or infections

SCHOOLING

• Special Abilities/Disabilities: Requires special education.

• Performance in Academics: Poor

• Number of Friends: 1 (a younger child)

• Relationship with Peers: Poor

• Co-curricular Activities: None

• Hobbies and Interests: None

SOCIAL AND PERSONAL HISTORY

1. Habits:

o Sleep: Normal

o Feeding: Requires assistance.

o Personal Care: Requires assistance.

2. Neurotic Traits: None

3. Behavior Problems: None

4. Play: Prefers solitary play or play with younger children.

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5. Sexual History: Not applicable (child).

PREMORBID PERSONALITY

• Social Relations:

o Family: Limited interaction, prefers solitary activities

o Friends: Minimal interaction, prefers solitary play

o Relatives: Limited interaction

• Intellectual Activities:

o Hobbies: None

o Interests: None

o Memory: Poor memory for recent events

o Observation: Limited observation skills

o Judgment: Impaired in social situations

• Mood of Client: Generally calm but becomes frustrated with complex tasks

• Character:

o Attitude to Work and Responsibility: Not applicable (child)

o Interpersonal Relationships: Limited interaction, prefers solitary activities

• Fantasy Life: Minimal daydreaming

• Habits:

o Eating: Requires assistance.

o Alcohol Consumption: Not applicable

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o Self-Medication: Not applicable

MENTAL STATUS EXAMINATION (MSE)

General Appearance and Behavior

• Appearance: Looking one’s age.

• Level of Grooming: Requires assistance.

• Level of Cleanliness: Adequate with assistance.

• Level of Consciousness: Fully conscious and alert.

• Mode of Entry: Came willingly.

• Cooperativeness: Normal.

• Eye-to-Eye Contact: Poor (avoids eye contact).

• Psychomotor Activity: Normal.

• Empathy: Difficult to establish.

• Quality of Rapport: Poor.

• Gesturing: Normal.

• Posturing: Normal posture.

• Other Movements: None (no mannerisms, stereotypes, tremors, EPS, AIMS, or

perseveration).

• Other Catatonic Phenomena: None.

Impression: Not Intact (poor eye contact and difficulty establishing rapport

Speech

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• Initiation: Speaks when spoken to.

• Reaction Time: Delayed.

• Speed: Slow.

• Output: Minimal.

• Pressure of Speech: Absent.

• Volume: Low.

• Tone: Monotonous.

• Manner: Highly formal.

• Relevance: Fully relevant.

• Stream: Normal.

• Coherence: Fully coherent.

• Others: None.

• Sample of Speech:

o Clinician: “What is your name?”

o Client: “R.K.” (spoken softly after a delay).

Impression: Not Intact (delayed reaction time, minimal output, and monotonous tone).

Thought

• Tempo: Normal.

• Form: Adequate.

• Obsession: None.

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• Compulsion: None.

• Thought Alienation Phenomena: None.

• Thought Commentary: None.

• Thought Contents:

o Idea: Difficulty understanding complex tasks.

o Overvalued Idea: None.

o Delusion: None.

Impression: Intact (no formal thought disorder).

Mood

• Subjective: Not elicited (child has limited verbal abilities).

• Objective: Calm but becomes frustrated with complex tasks.

• Predominant Mood State: Euthymic.

• Other Major Moods: None.

• Range: Restricted.

• Reactivity: Reactive.

• Quality of Mood: Calm.

• Communicability: Poor.

• Lability: None.

• Appropriateness: Appropriate to thought content.

• Congruence: Mood congruent.

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• Emotional Expression: Blunted.

Impression: Intact (mood is congruent with affect).

Perception

• Hallucination: None.

• Illusion: None.

• Depersonalization: None.

• Déjà Vu Phenomena: None.

• Somatic Passivity: None.

• Special: None.

Impression: Intact (no perceptual abnormalities)

Cognitive Functions

• Attention: Normally aroused but easily distracted.

• Digit Forward: 3/5.

• Digit Backward: 2/5.

• Concentration: Sustained with difficulty.

• 100-7 Test: Unable to complete.

• 40-3 Test: Unable to complete.

• 20-1 Test: Unable to complete.

• Months Backwards: Unable to complete.

• Weekdays Backwards: Unable to complete.

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Impression: Not Intact (attention and concentration are impaired).

Orientation

• Time: Approximate time (knows day but not date or month).

• Place: Kind of place (knows he is in a clinic).

• Person: Self and close associates (recognizes himself and family members).

Impression: Partially Intact (oriented to place and person but not fully to time).

Memory

• Immediate: 2/3 objects recalled immediately.

• Recent: Recalls last meal but not visitors.

• Verbal Recall:

o After 5 minutes: 2/3 objects.

o After 10 minutes: 1/3 objects.

• Visual Recall: 2/3 objects recalled.

• Remote: Recalls personal events but not impersonal events.

Impression: Not Intact (memory is impaired).

Intelligence

• Comprehension: Understands simple commands.

• Vocabulary: Limited (can name common objects).

• Arithmetic Ability: Unable to perform mental arithmetic.

• General Fund of Information:

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o Literate: Knows his name and basic objects.

o Current Events: Unaware of current events.

Impression: Not Intact (intelligence is below average).

Abstraction

• Interpretation of Proverbs: Unable to interpret.

• Similarities Between Paired Objects: Concrete.

o “Apple and orange” interpreted as “Both are fruits.”

• Dissimilarities Between Paired Objects: Unable to identify.

Impression: Not Intact (abstract thinking is impaired).

Judgment

• Personal: Impaired (unable to plan or complete tasks).

• Social: Impaired (does not understand social norms).

• Test: Impaired (unable to predict consequences of actions).

Impression: Not Intact (judgment is impaired).

DIAGNOSTIC FORMULATION

• Major Diagnosis: Intellectual Disability, Mild (F70, ICD-10)

• Differential Diagnosis:

o Autism Spectrum Disorder (F84.0, ICD-10)

o Global Developmental Delay (F88, ICD-10)

• Associated Diagnoses: None

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PSYCHOPATHOLOGY

R.K., a 10-year-old boy, presents with significant delays in speech and language

development, poor academic performance, and impaired adaptive functioning since early

childhood. He has difficulty understanding instructions, requires assistance with daily

activities, and has limited social interactions, preferring solitary play or engaging with

younger children. His cognitive assessment reveals deficits in attention, memory, intelligence,

and abstract thinking, with impaired judgment and poor verbal output. The clinical picture is

consistent with Intellectual Disability (Mild), with differential considerations including

Autism Spectrum Disorder and Global Developmental Delay. Given his functional

impairments, intervention strategies should focus on special education, speech therapy,

occupational therapy, and family counseling to enhance his adaptive skills and overall quality

of life.

PSYCHOTHERAPY AND MANAGEMENT

• Medications: None (behavioral interventions preferred).

• Therapy: Special education, speech therapy, occupational therapy

• Social Support: Family counseling, community support programs

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