CASE STUDY – 5

Name : TY
Age : 17 Years
Gender : Female
Marital Status: Unmarried
Occupation : Student
Education : 10th Pass
Religion : Hindu
Residence : Urban
Language : Hindi & English
Informant : Father, Mother, Elder Sister and Client Herself

Reliability & Adequacy: Fair

Chief Complaints:

According to the Client:

 Constant fear in taking any decisions, plans, actions – 4 years

 Sleep is disturbed due to this continuous fear of getting low marks– 2 years

 Feeling lonely and the thought that no one loves her and can‘t understand her - 2 years
According to the Informants:

 Consumes excess churans with the thought of performing better in academics – 2 years
months

 Habit of sleeping with the books under her pillow with the belief that everything would
get inside her brain and studies almost nothing – 15 months


 Involved in unusual behaviours such as jumping off the roof with the belief of getting
good marks – 2 weeks back


Precipitating Factors

 Parents pressurization to get more marks

Perpetuating Factors

 Lack of caring from parents and unfavorable conditions at home for the behaviour.

Predisposing Factors

There is no biological factor such as genetic vulnerability, but from the personality factor, the patient
being more impulsive and might have accounted.
 Mode of Onset: Gradual

Duration: From Past 4 Years

Progress: Stable

Course: Continuous

History of Present Illness:

The client was apparently normal till 9th grade, had a lot of friends in her neighborhood and used
to spend time with them. The client was average in her academics till 9th std. and was very
active in extracurricular activities like drawing, playing piano etc.

According to the client's mother she started observing these unusual problems after she scored very
low in her 9th std and parents scolded her, after that she started getting overly involved in
superstitious activities slowly, going to temples and eating churans.

The behaviours persisted continuously and parents did not give that importance to the behaviour
until a week back the client tried jumping off the roof with the belief that she would gain good
marks in examination.

Negative History:

NIL

Positive History:

NIL
 Treatment History:

 For present Illness:

The clients do not have any significant treatment history for the present illness

Medical History:

No significant medical history is reported by the client and the informant

Psychiatric History:

No history of past psychiatric illness

Family History:

• Family size : 4 members

• Nuclear family
• Birth order : 2nd
• Interpersonal relationship: Not Pleasant
• Home atmosphere: Not Supportive
• No h/o any medical or psychiatric illness in the family

Family Interaction Pattern

1. Communication – The client does not have open communication with family
members.
2. Leadership – The client‘s father is one who make decision making at home and
the client abides to it
3. Decision making – Usually the client herself decides and gets irritated if any
others interfere.
4. Role – Dominating role towards parents.
5. Family Rituals – The family has no ritual of having breakfast and dinner together
every day, as the patient sleeps during the day time.
6. Cohesiveness – Absent
7. Family burden – No significant family burden mentioned.

Expressed Emotions – Hostility (Family believed that the problems are actually created by the client and
the client don't want to get well)
Personal History:

Prenatal:

Pregnancy was full term

Type of birth: Normal
Normal cry at Birth

Early Childhood:

• Developmental milestones attained at appropriate age

• No h/o temper tantrums, tics, head-bumping, rocking
• Was introvert and obedient child.
• Client used to cry frequently if mother was not around
• Less Interaction with others.

Middle Childhood:

• Started schooling at 3yrs

• No history of usually impulsive behavior, fire setting, cruelty to animals, bed wetting,
nail biting

Late Childhood and Adolescence:

• Late childhood Cordial relations with teachers, classmates and relatives

• Prefer to keep to her, did not have any close friend

Psychosexual History:

Acquired sexual knowledge from mother and close friends

Socio-Economic Status:

• Does not have a good social circle

• Lives in an apartment alone, has stayed with mother on and off and does visit her
• Adequate privacy and sanitation facilities
• Her family monthly income: higher income group
Premorbid personality

Attitude towards self and others- Before the onset of present illness, the patient was friendly,
caring, trusts others, sustained and maintained good relationships with his peers, family
members.

Moral & Religious attitudes and standards-The patient conformed to moral standards and she is
over religious compared to her other family members.

Work and Leisure- The patient used to spend his leisure time with his family members.

Mood- The patient had the stable mood and he was able to express her feelings

Fantasy Life- The client always was in her fantasy life.

Habits- The premorbid biological functions such as eating, sleeping and excreting are reported to
be normal.
 MENTAL STATUS EXAMINATION

General Appearance & Behaviour:

• Appearance: The patient is a young woman appearing appropriate to her stated age. She was
well kempt and neat.

• Touch with the surroundings: Normal.

• Eye Contact: Well established and sustained. (There is no fixed, glaring, darting eye contact.)

• Rapport: Easily established and sustained.

• Attitude towards Examiner: Co-operative in providing information but she was providing
information which was only favorable to her

Movement and Behaviour:

• Gait: normal (there were no brisk, slow, hesitant or uncoordinated movements)

• Handshake: Stern and confident.

• Abnormal movements: There are no tics, foot tapping, ritualistic behaviour, and nail Biting.

• Rate of movements: normal

• Coordination of movements: Normal (no presence of awkward, clumsy movements) Speech:

• Intensity / Tone: Normal

• Reaction Time to Stimulus: normal

• Speed: Ordinary

• Prosody / Tempo: Normal

• Ease of Speech: intact

• Productivity / Volume: normal.

• Coherent/ Non coherent: Coherent

• Goal Directed/ Non goal directed: Goal directed.

Mood and Affect:

• Subjectively: normal but shows decreased energy due to lack of sleep

• Objectively: Normal

• Depth:

• Range: Normal

• Congruent to the Thought/ not congruent to the Thought: congruent to the thought.

• Appropriate/ inappropriate to the Situation: Appropriate

• Communicable / not communicable: Communicable.

Thought:

• Stream- Normal (thought blocking is not present.)

• Form-There is no evidence of flight of ideas, loosening of associations, tangentially, and

circumstantiality
• Possession- No presence of thought withdrawal, insertion and broadcasting.

• Content- no abnormal thought is present but feels that the patient feels no difference in the
presence and absence of his parents.

Perception:

• Auditory hallucinations nil

Cognitive Functions:

• Orientation: The patient is alert and intact to person, place and time.

• Attention & Concentration: Normal

• Memory:

➢ Immediate memory: claims to have problem but when the patient was made to perform
forward and backward digit span the patient did not show any difficulties.

➢ Recent memory: Intact.

➢ Remote memory: Intact as evidenced by his detailed recall of past events like the name of the
medicines etc.

• Abstraction: concrete/ conceptual/ functional: concrete

• General fund of knowledge: Average.

• General Intelligence: Above average.

Judgement:

Personal: intact
Social: intact
Test: Intact

Insight: Level 1 Complete denial of illness.

Provisional diagnosis: In reference of ICD-10

Obsessive-compulsive disorder, unspecified

F42. 9

Points in favor:
● Fears that if she doesn't do certain things in a certain way, something bad will happen
(fear something bad will happen to themselves or a loved one) to her (scoring low
marks in exam)
● Superstitious thoughts and an extreme fear of superstitions
● Follow a certain ritualistic pattern repeatedly until anxiety diminishes
 CASE STUDY – 8
Socio-demographic Data:

Name : XYZ
Age : 16 years
Gender : Female
Marital Status: Unmarried
Occupation : Student
Education : Studying in Class 12th
Religion : Hindu
Residence : Urban
Language : Hindi
Informant : Class teacher and Client
Referred By: Class Teacher

Reliability & Adequacy: Fair

CHIEF COMPLAINT:

As per informant (teacher)

 She does not interact with other students.
 She does not participate in group activities.
 Parents do not participate in her school activities
 Her Father is alcoholic, once he came in PTM. He was drunk.
As per Client
 Kisi se baat karne ka man nahi hota
 Padhai mein mann nahi lagta
 Dar sa lagta rahta hai.
 Ghar jaane ka man nahi hota. Ghar mein ladai hoti hai to sar dard karta hai.
COURSE- Continuous

DURATION – one year

ONSET-
 Abrupt ( within 24-48 hrs) -
 Acute (1-1 and a half)
 Insidious ( 1 month or more)
 Chronic
 Precipitating factor- Psychological

HISTORY OF THE PRESENT ILLNESS:

Patient had been complaining of trust issues. She hesitates while talking to peers in class and
generally keeps it to herself. She got irritated if others tried to approach her for interaction.
She avoided group activities. Generally sits alone during break time. If coaxed to perform
in a group activity, her hands started to shiver so she preferred to be dormant during the
group work. She did not want to talk about her family with anyone.

 How is your appetite for past one week - Increased/Decreased/Normal

 How is your sleep pattern for past one week- Increased/Decreased/Disturbed/Normal
 Have you taken treatment /assessment from someone before- No
FAMILY HISTORY

Patient has been living with her parents and sister in a resettlement colony. Father is
alcoholic and mother has been working as maid. Father does not work and earn. So family
is being run by the mother. Her younger sister is studying in V class in Govt School.

 Family structure: Nuclear/Joint/Separated

 Parenting style: Authoritarian/Permissive/Neglect
 Attachment style; Secure/Insecure
 Relationship with patient between other family members: Cordial/Ineffective
 Pattern of communication: Effective/Ineffective.

FAMILY HISTORY OF ILLNESS: Mental illness/Intellectual Disability, Suicide,
Alcohol/Drug dependence, Epilepsy/Organic disorder or any other significant physical illness-

- Father is alcoholic. He misbehaves with family members.

SCHOOL HISTORY;
 School performance : Poor/Average/Above average
 Any class repeated : No
 Attendance ; Poor/Average/Above average

BEHAVIOR CHECKLIST: In attention/Anger/Disobedience/Temper Tantrum/Thump

sucking/Low self-esteem /Poor time Management/Peer issues/Bed wetting/Sibling issues.

Low self esteem

(A) PRE-NATAL FACTORS (STATE OF MOTHER DURING PREGNANCY)

(a) Conception: Planned/unplanned- Planned

Wanted/unwanted - Wanted
(b) Health of the mother: Nutrition status- Healthy/ average /poor-Healthy
Psychological: stressor/Trauma/Abuse-
(c) Exposure to Fetus: Alcohol/Drugs/Radiation/Medication/any other- NO

(d) Infections: chicken pox/fever without symptoms/Venereal diseases- NO

(e) Physiological /Psychological illness- None

 (B) PERINATAL FACTOR (INCLUDING NEONATAL)

 Term – Full/pre/post/Induced
 Delivery place- Home/Hospital/others ( please specify)
 Type- Normal/Caesarean/Forceps /Vacuum
 Head injury- during birth – yes/No /Not known

(C) POST NATAL FACTOR

 Infections: Yes/No/Not known

 Feeding problems : Yes/No/Not Known
 Injury: Yes/No/Not Known
 Convulsions fits: Yes/No/Not Known
 Feeding history : Breast feeding- Exclusive /Mixed /Bottle ( till 4 years)

DEVELOVEMENT HISTORY:- Normal

PRE-MORBID PERSONALITY:-

 Pre morbid mood- Pessimistic

 Use of leisure time- No use of leisure time
 Attitude to self -- Self-conscious, good
 Habits- - No specific habit
 Character traits - Introvert
 Initiative- - Low on initiation

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE AND BEHAVIOUR

 Appearance : Healthy /Bizarre/Any other- Poor at hygiene, hairs ungroomed,

Shoes unpolished
 Facial expression : Appropriate /changing with subject/overt emotional displays
 Posture : Guarded/Relaxed/Bent/Erect
 Gait; Normal /Brisk/Slow /Unsteady/Poorly coordinated
 Eye Contact: Maintained/Not maintained/Fluctuating
 Dress: Neat & Clean/Dirty /Torn
 Motor behaviour: Increased /Restless/constantly moving/Decreased
 Rapport: Established easily/with difficulty/not established
 Attitude towards the examiner:
Cooperative/Friendly/attentive/increased/defensive/apathetic/hostile/ guarded
 MOOD & AFFECT: Euthymic/Anxious/Depressed/Irritable/Elevated/Normal.

He comfortably walked in to the room.

SPEECH:
 Form of speech: Relevant & Coherent/Irrelevant & Incoherent
 Rate and quantity of production: Rapid/Slow/Easy/Hesitant/Pressured
 Pitch: High/Low/Std/Excited
 Tone: Monotonous/Moody/Sad/Happy/Excited/Aggressive/Normal
 Reaction time: Slow/Fast/Spontaneous
 Any abnormalities; Slurring/Stuttering/Articulation/Stammering- NO

CONSCIOUSNES: Time/Place/Person- Patient was conscious

ATTENTION& CONCENTRATION - She is able to sustain her attention towards the conversation but
showed hopelessness about improvement in her condition.

ABSTRACT THINKING: Poor/Average/Good

JUDGEMENT:

 PERSONAL (assisted by asking about personal situations or future plans. Do

you take a bath daily? Able to follow daily routine? Where do you yourself in
the next 5 years? - Yes


 SOCIAL (Behavior towards others, social/work responsibilities. Do you go to

school work daily? What else do you in school? Do you take your children for
outing? Do you like meeting people)


 TEST (assessed by evaluating reacting to situations. If you are on the road and
see a letter with an address on it, what will you do if your house catches fire ) -
 INSIGHT:

(Why you are here? Do you think you have a concern? Do you need treatment?)
i) Complete denial of illness -
ii) Slight awareness of being sick and needing help but denying at the same time.
iii) Awareness of being sick but blaming it on others, on external factors, on medical or
unknown organic factors.
iv) Awareness that illness is due to something unknown in the patient. -
v) Intellectual insight ( admission of illness and recognition that symptoms or failure in
social adjustment are due to irrational feelings or disturbances, without applying that
knowledge to future experiences)
vi) True Emotional Insight ( emotional awareness of the motives and feelings within ,of
the underlying meaning of symptoms, openness to new ideas and concepts about self and
the important persons in his/her life, the awareness leads to changes in personality and
future behaviour)-Yes

INTERVIEW SESSION
AIM: Exploration and assessment of the client‘s problem and building rapport.

START OF THE SESSION

The patient came in. She looked low on energy and sluggish. She did not initiate to wish me. So I wished her
good morning and told her to sit.

She looked dazed & confused. She appeared uninterested to talk. So I asked her to feel
comfortable & sit down.

She sat. I told her that I am a counsellor. She asked me: aap kya karte ho?

I told: main students ko unki problem ke solutions deta hun.

Patient: Apne mujhe yaha kyu bulyaya hai?

I told: muje pata chala ke apke friends nahi hain, aap zyada baat nahi karte kisi se class
mein.
She got silent when I said that. I asked her if I am correct! She did not revert. I repeated my
question.

Patient: haan muje zyada baat cheet achi nahi lagti.

I told: kyu?
Patient: kisi pe bharosa nahi ho pata na mujse

I told: kyu?

Patient: ajeeb sa lagta hai?

I told: kis bare mein?

Patient: kisi se kuch bhi share karne mein.

I told: par aap mujse abhi share hi to kar rahe ho.

Patient: haan par aap dost nahi ho na.

I told: kya doston se kuch share nahi kiya jata?

Patient: dost hona bhi tau chahiye koi.

I told: par apki class mein to bahut girls hain.

Patient: haan par sab mazaak banate hain. Ek baar mere papa PTM mein sharaab pee kar
aa gaye the, tab se sab mera Mazak banane lage muje acha nahi lagta to mai kisi se kuch
nahi kehti.

I told: kya papa ghar mein bhi sharab peete hain?

Patient: haan!!
I asked her of what her parents does. She replied that mother works as a maid and father is
an alcoholic so he does not work anywhere. She was embarrassed to share such details
of her family. I offered her water to calm her down. We took a pause for 01 minute. This
pause gave us the space to revive our energies.

I asked: are you comfortable? Are you ok?

Patient: yes

I told: kya mujse ye baat share karke apko thik laga?

Patient: haan par muje dar hai ke aap ye baat kisi ko bata na do? (she covered her face with
her hands while saying this)
I assured that I won‘t share these details with anyone. I asked her if I can call other students
in the room for the time being for a group activity to make her feel diverted, to which
she refused. I asked her the reason of refusal.
 Patient: muje group mein kaam karne mein sharm ati hain. (she looked upon the floor and
did not give eye contact)

I told: kyu?

Patient: wo meri baat nahi samjhe tau?

I told: kyu nahi samjhenge?

Patient: ghar pe bhi to koi nahi samajhta!! Aapas mein ma-papa jhagadte hain, mai rokne ki
koshish karti hun to sunte nahi. Sar dard rehta hain mujhe.

I told her that they are your classmates who are of the same age group, there must be some
of them that she can probably trust and interact with. It will also help her to develop her
personality and confidence.

Patient: mere haath kapte hain sabke samne bolne mein. Aisa lagta hain wo kya sochenge
mere bare mein!!

I told her that she should feel positive and confident about her own personality first, once
she is confident everything else shall fall in place gradually. I explained that there are certain
things in life which are beyond our control (her father alcoholism) but for other things related to her life
she must take charge of.

The time allotted for the session was 50 minutes so I ended it by reminding her that she is strong enough
to feel positive about herself. Her confidence in herself shall build the foundation of her relationships with
others. She must recognise her potentials and should not give space to self-doubts or inhibitions to
interfere in her path of success.

I asked her if she would like to see me again to discuss and open up about her thoughts and feelings, to
which he agreed. We fixed upon to meet in the coming again. We both stood and I patted her back before
she left for her class.

Outcome

The patient looked relaxed towards the end of the session. Talking about her issues and
verbalizing her feelings eased her out to some extent. She showed improvement in
communication. There is possibility that she would gain confidence after few sessions.
 DIAGNOSIS: Low Self- esteem, Confidence Issues and Anxiety (Mild)

TREATMENT

Plan of action:

Relaxation technique:-The child is asked to take deep breath through nose and release
through mouth. It is a happy technique of ―Balloon ―in the belly to have fun. This
increases intake of oxygen to the brain and reduces stress. This technique brings positive
result in reducing stress/anxiety.

Psychotherapy:- It is a kind of talk therapy where therapist focuses on current ability to

function , makes client learn to manage emotions that make her uncomfortable
,reduce impulsive behaviour by observing feelings rather acting on them ,make client
aware of others feelings.
Self-help techniques:- in this technique, patient learns to handle situation, focuses on productive non –
threatening things, deep breathing techniques, challenge fears, creative visualization.
 CASE STUDY – 3
Socio-demographic Data:

Name : XYZ
Age : 15 years
Gender : Female
Marital Status: Unmarried
Occupation : Student
Education : Studying in Class 11th
Religion : Hindu
Residence : Urban
Language : Hindi
Informant : Class teacher and Client
Referred By: Class Teacher

Reliability & Adequacy: Fair

CHIEF COMPLAINT:

As per the informant

 Not interested in studies

 Difficulty in concentration and focus in the classroom.
 More interested in games. Therefore scores are poor

As per mother

 Fond of play station games more than enough

 Conversations are central to games and cars alone.
 Speak lies
COURSE- Progressive

Duration – Since 9th grade .severity increased in 11th class

ONSET-

 Abrupt ( within 24-48 hrs)

 Acute (1-1 and a half)
 Insidious ( 1 month or more)
 Chronic

HISTORY OF THE PRESENT ILLNESS:

 According to mother suffered from jaundice on 6th day of birth

 Hospitalized for 10-15 days due to fits at the age of 2 months
 To show reluctance for going out, he bangs his head on the wall.
 On persuasion he understands and agrees.
 When glad, eats large portions at a time.
 How is your appetite for past one week - Increased/Decreased/Normal
 How is your sleep pattern for past one week- Increased/Decreased/Disturbed/Normal
 Have you taken treatment /assessment from someone before- Yes/N0 , if yes ,kindly
give the details— Sleep decreased due to play station games

FAMILY HISTORY

 Family structure: Nuclear/Joint/Separated

 Parenting style: Authoritarian/Permissive/Neglect
 Attachment style; Secure/Insecure
 Relationship with patient between other family members: Cordial/Ineffective
 Pattern of communication: Effective/Ineffective
 Boundaries- Rigid/Flexible/Permissible/Diffused

FAMILY HISTORY OF ILLNESS:

Mental illness/Intellectual Disability, Suicide, Alcohol/Drug dependence,

Epilepsy/Organic disorder or any other significant physical illness-
-Mother has thyroid issue
- Father has Hypertension
SCHOOL HISTORY;

School performance: Poor/Average/Above average

Any class repeated: No
Attendance : Poor/Average/Above average
Academic Difficulty: writing/comprehension
Writing: Slow

BEHAVIOR CHECKLIST: In attention/Anger/Disobedience/Temper Tantrum/Thump

sucking/Low self-esteem /Poor time Management/Peer issues/Bed wetting/Sibling issues.

Poor Time Management

A) PRE-NATAL FACTORS (STATE OF MOTHER DURING PREGNANCY)

(a) Conception: Planned/unplanned- Planned

Wanted/unwanted - Wanted
(b) Health of the mother: Nutrition status- Healthy/ average /poor-Healthy
Psychological: Stressor/Trauma/Abuse-
(c) Exposure to Fetus: Alcohol/Drugs/Radiation/Medication/any other- NO

(d) Infections: chicken pox/fever without symptoms/ Venereal diseases/other- No

(e) Physiological/Psychological issues- No

(B) PERINATAL FACTOR (INCLUDING NEONATAL)

-Term – Full/pre/post/Induced
-Delivery place- Home/Hospital/others (please specify)
-Type- Normal/Caesarean/Forceps /Vaccum
-Head injury- during birth – yes/No /not known
 (C) POST NATAL FACTOR

 Infections: Yes/No/Not known

 Feeding problems : Yes/No/Not Known
 Injury: Yes/No/Not Known
 Convulsions fits: Yes/No/Not Known - After 2 months hospitalized for 10-15 days
 Feeding history : Breast feeding- Exclusive /Mixed /Bottle ( till 4 years)

DEVELOVEMENT HISTORY:- Normal

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE AND BEHAVIOUR

 Appearance : Healthy /Bizarre/Any other

 Facial expression : Appropriate /changing with subject/overt emotional displays
 Posture : Guarded/Relaxed/Bent/Erect
 Gait; Normal /Brisk/Slow /Unsteady/Poorly coordinated
 Eye Contact: Maintained/Not maintained/Fluctuating
 Dress: Neat & Clean/Dirty /Torn
 Motor behaviour: increased /Restless/constantly moving/Decreased
 Rapport: Established easily/with difficulty/not established
 Attitude towards the examiner:
Cooperative/Friendly/attentive/increased/defensive/apathetic/hostile/ guarded

MOOD & AFFECT: Euthymic/Anxious/Depressed/Irritable/Elevated/Normal

SPEECH:
 Form of speech: Relevant &Coherent/Irrelevant & Incoherent
 Rate and quantity of production: Rapid/Slow/Easy/Hesitant/Pressured
 Pitch: High/Low/Std/Excited
 Tone: Monotonous/Moody/Sad/Happy/Excited/Aggressive/Normal/
 Reaction time: Slow/Fast/Spontaneous
 Any abnormalities; Slurring/Stuttering/Articulation/Stammering

ORIENTATION
Time; Place: Person;
ATTENTION& CONCENTRATION- Poor concentration

ABSTRACT THINKING: Average

JUDGEMENT;
 PERSONAL (assisted by asking about personal situations or future plans. Do
you take a bath daily? Able to follow daily routine? Where do you yourself in
the next 5 years? -- No
 SOCIAL (Behavior towards others, social/work responsibilities. Do you go to
school work daily? What else do you in school? Do you take your children for
outing? Do you like meeting people) – No( Sometimes)
 TEST (assessed by evaluating reacting to situations. If you are on the road and
see a letter with an address on it, what will you do if your house catches fire ) -
Average

Insight:
(Why you are here? Do you think you have a concern? Do you need treatment?)
Complete denial of illness
i) Slight awareness of being sick and needing help but denying at at the same
time.
ii) Awareness of being sick but blaming it on others, on external factors, on
medical or unknown organic factors.
iii) Awareness that illness is due to something unknown in the patient.
iv) Intellectual insight ( admission of illness and recognition that symptoms or
failure in social adjustment are due to irrational feelings or disturbances, without
Applying that knowledge to future experiences)
v) True Emotional Insight ( emotional awareness of the motives and feelings
within ,of the underlying meaning of symptoms, openness to new ideas and
concepts about self and the important persons in his/her life, the awareness leads
to changes in personality and future behaviour)
INTERVIEW SESSION

Aim: Exploration and assessment of the client‘s problem and building rapport.

Start of the Session:

The patient came with his mother. He looked low on energy and sluggish. He did not
initiate to wish me. So I wished them good morning and asked them to sit. I asked the
boy if he would like to interact with me, if his mother is asked to sit outside for some
time. The boy agreed on it, though he was hesitant.

I ensured him of his comfort and cooperation. I made rapport with him by asking his
likes and dislikes. While interacting he told me about his interest/indulgence in video
games especially play station. Most of his conversation was about games. When I asked
about his studies, his interest seemed diminished and he questioned me, ‘why our
studies have subject on games? On asking whether he is able to concentrate on his
studies, he told me ‘I see only cars, bikes, racing and competing in it.‖

After finishing conversation with him, I called his mother and conversed with her.
During conversation she informed that he had jaundice on 6th day of his birth, had fits
when he was 2 months old. His eating habits changed after that.

I observed that the pitch of the client was low; he did not seem to be attentive and
wanted to go to his home.

After conversation I understood what is needed to be done. She was told that some
psychological tests and therapies are required to be done. His mother agreed for another
session.

They left after exchanging greetings.

 DIAGNOSIS: Video games addiction

Management plan:

Cognitive Behavioral Therapy:

This therapy allows the patient to divert his mind and thoughts and replace them with
positive and healthier thinking. It makes patient to learn overcome the thinking that causes
compulsion for games.

Self-control training techniques: The counsellor helps in reducing the urge by giving self-
control training programme.

Individual counseling: It helps the patient to focus on his goals in life. This shifts s the
thought process towards useful things.

Environmental Intervention: The support of surroundings defeating a thought of doing

addicted activity is useful. Here family, friend and society can play an important role.
 CASE STUDY – 6
Socio-demographic Data:

Name : XYZ
Age : 11 years
Gender : Female
Marital Status: Unmarried
Occupation : Student
Education : Studying in Class 6th
Religion : Hindu
Residence : Urban
Language : Hindi
Informant : Father and Client
Referred By: Class Teacher

Reliability & Adequacy: Fair

CHIEF COMPLAINT:
As per teacher
 Not interested in studies
 Lack of concentration in the class
 Low confidence
 Therefore scores are poor

As per father

 Child has school phobia, excessive sweating

 Anger, she breaks things, adamant.
 Refuses to go to school, changes clothes 3-4 times before going to school.
 Gets annoyed frequently without any reason
COURSE- Static

Duration – one month

ONSET-
 Abrupt ( within 24-48 hrs) Precipitating/Triggering factors
 Acute (1-1 and a half) New School, sitting arrangement
 Insidious ( 1 month or more) Perpetuating/Maintaining Factors- School
 Chronic- Protective factors

HISTORY OF THE PRESENT ILLNESS:

 She has taken admission in New School due to her father‘s transferable job.
 Sitting arrangement is bothering her since a boy and a girl sits alternatively.
This creates anxiety to her.

 How is your appetite for past one week - Increased/Decreased/Normal

 How is your sleep pattern for past one week- Increased/Decreased/Disturbed/Normal
 Have you taken treatment /assessment from someone before- Yes/N0

FAMILY HISTORY
 Family structure: Nuclear/Joint/Separated
 Parenting style: Authoritarian/Permissive/Neglect
 Attachment style: Secure/Insecure
 Relationship with patient between other family members: Cordial/Ineffective
 Pattern of communication: Effective/Ineffective
 Boundaries: Rigid/Flexible/Permissible/Difficult

FAMILY HISTORY OF ILLNESS:

Mental illness/Intellectual Disability, Suicide, Alcohol/Drug dependence, Epilepsy/Organic
disorder or any other significant physical illness-
- She is the only child and has got excessive love .She gets annoyed when threatened
to adopt another child. Her mother reported similar problem at the age of 11 yrs
before attaining puberty.
- Father has Hypertension
SCHOOL HISTORY;
School performance: Poor/Average/Above average
Any class repeated: No
Attendance : Poor/Average/Above average
Academic Difficulty: None

BEHAVIOR CHECKLIST: In attention/Anger/Disobedience/Temper Tantrum/Thump

sucking/Low self-esteem /Poor time Management/Peer issues/Bed wetting/Sibling issues.

Anger/Temper tantrum

(A) PRE-NATAL FACTORS (STATE OF MOTHER DURING PREGNANCY)

(a) Conception: Planned/unplanned- Planned

Wanted/unwanted - Wanted
(b) Health of the mother: Nutrition status- Healthy/ average /poor-Healthy
Psychological: stressor/Trauma/Abuse- None
(c) Exposure to Fetus: Alcohol/Drugs/Radiation/Medication/any other- NO

(d) Infections: chicken pox/fever without symptoms/ Venereal

diseases/other- NO

(e) Physiological /Psychological illness- No

(B) PERINATAL FACTOR (INCLUDING NEONATAL)

-Term – Full/pre/post/Induced
-Delivery place- Home/Hospital/others (please specify)
-Type- Normal/Caesarian/Forceps /Vaccum
-Head injury- during birth – yes/No /not known

(c)POST NATAL FACTOR

 Infections: Yes/No/Not known

 Feeding problems : Yes/No/Not Known
 Injury: Yes/No/Not Known
 Convulsions fits: Yes/No/Not Known - after 2 months hospitalized for 10-15 days
 Feeding history : Breast feeding- Exclusive /Mixed /Bottle ( till 4 years)
 DEVELOVEMENT HISTORY:- Normal

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE AND BEHAVIOUR

 Appearance : Healthy /Bizarre/Any other

 Facial expression : Appropriate /changing with subject/overt emotional displays
 Posture : Guarded/Relaxed/Bent/Erect
 Gait; Normal /Brisk/Slow /Unsteady/Poorly coordinated
 Eye Contact: Maintained/Not maintained/Fluctuating
 Dress: Neat & Clean/Dirty /Torn
 Motor behaviour: increased /Restless/constantly moving/Decreased
 Rapport: Established easily/with difficulty/not established
 Attitude towards the examiner:
Cooperative/Friendly/attentive/increased/defensive/apathetic/hostile/ guarded

MOOD & AFFECT: Euthymic/Anxious/Depressed/Irritable/Elevated/Normal

SPEECH:
 Form of speech: Relevant & Coherent/Irrelevant & Incoherent
 Rate and quantity of production: Rapid/Slow/Easy/Hesitant/Pressured
 Pitch: High/Low/Std/Excited
 Tone: Monotonous/Moody/Sad/Happy/Excited/Aggressive/Normal
 Reaction time: Slow/Fast/Spontaneous
 Any abnormalities; Slurring/Stuttering/Articulation/Stammering- NO

ORIENTATION

Time: Place: Person:

ATTENTION& CONCENTRATION- NORMAL

ABSTRACT THINKING: Poor/Average/Good

 JUDGEMENT;

 PERSONAL (assisted by asking about personal situations or future plans. Do you take a
bath daily? Able to follow daily routine? Where do you yourself in the next 5 years?

 SOCIAL (Behavior towards others, social/work responsibilities. Do you go to school work

daily? What else do you in school? Do you take your children for outing? Do you like meeting
people) –
 TEST (assessed by evaluating reacting to situations. If you are on the road and see a letter
with an address on it, what will you do if your house catches fire )

Insight:

(Why you are here? Do you think you have a concern? Do you need treatment?)

vi) Complete denial of illness

vii) Slight awareness of being sick and needing help but denying at at the same time.

viii) Awareness of being sick but blaming it on others, on external factors, on medical or
unknown organic factors.
ix) Awareness that illness is due to something unknown in the patient.

x) Intellectual insight ( admission of illness and recognition that symptoms or failure in social
adjustment are due to irrational feelings or disturbances, without applying that knowledge to
future experiences)

xi) True Emotional Insight ( emotional awareness of the motives and feelings within ,of the
underlying meaning of symptoms, openness to new ideas and concepts about self and the
important persons in his/her life, the awareness leads to changes in personality and future
behaviour)

INTERVIEW SESSION
AIM: Exploration and assessment of the client‘s problem and building rapport.

START OF THE SESSION

The girl came with her father. I greeted them and asked them to sit. I asked her father to sit outside
so that she could share openly what she feels.
 The girl was making eye contact. I asked her to be relaxed. Told her that I am counselor and would
like to hear her problem and try to solve her problem. She was willing to share. I asked her about
herself. She started telling me about her likes and dislikes, hobbies. She told me,‖ I do not want to
come to this school‖. Upon asking the reason she told me in low pitch ,‖ In our school, girls are
made to sit between two boys. I don‘t feel comfortable sitting that way.‖ I asked her the reason of
her being uncomfortable. She replied that ‗They have harsh voice and use rough language and
smell bad. I feel like a rat trapped in a cage.‖ After finishing conversation with the girl and
ensuring her confidentiality, I called her father.

Her father seemed anguished and told that she starts sweating when ask to get ready to go to school.
She gets angry to the extent to breaking the things. She changes the clothes 3-4 times before going
to school. I told him that the girl has anxiety about her present condition and has aversion for boys.
They asserted what I assessed. I told them that we can fix the session for next week for some
psychological tests to check the intensity of the problem and appropriate treatment plan.

DIAGNOSIS:- The client has been diagnosed with anxiety and aversion to boys.

TREATMENT
(1) Behavioral contract:- Agreement is made between parents and child where expectations
of both are mentioned and both will abide by that. This reduces the conflict and created a
better understanding.

(2) Relaxation technique:- The child is asked to take deep breath through nose and release
through mouth. It is an happy technique of ―Balloon ―in the belly to have fun. This
increases intake of oxygen to the brain and reduces stress. This technique brings positive
result in reducing stress/anxiety.

(3) Cognitive behaviour therapy:- (story telling) - child is educated by telling stories of
gender sensitization. This sensitizes the child about aversions to boys. As a result child is
able to interact with every gender properly.

(4) Systematic desensitization:- In this technique, client is made to feel what she feels when
sits with opposite gender. She is asked to imagine in that situation and relax herself. As
soon as she starts to feel anxious she will again start relaxing.

Supportive psychotherapy:- Client is made to feel adequate in facing her issues confidently. Counsellor
helps to make aware of her potential.