1

CASE 1

SOCIO – DEMOGRAPHIC DATA

Name : Master P
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Date of birth & Age : 20.06.2018 & 5 years and 9 months

Gender : Male
Education : Preschool (Discontinued)
Order of birth : First child
Family type : Nuclear
Father occupation : Business
Mother occupation : Physiotherapist
Language : Tamil
Religion : Hindu
Area of residence : Ariyankuppam
Rular/Urban : Urban
Referred by : Self
Informant : Mother
Information : Reliable and adequate

PRESENTING COMPLAINS

 Speech is not adequate 1 years 6 months

 Unable to comprehend the instruction
 Restlessness and unable to complete the task
 Not mingle with others
 Poor in eye contact for past 3 years
 Enjoying his own play
 Unable to accept his routine changes

HISTORY OF PRESENTING ILLNESS

Mode of onset : Insidious

Course of illness : Continuous
Progress : Improving
Perpetuating factor : Father had speech delay during childhood. He had started one
syllable word at the age of three and half years remaining all developmental milestone was
appropriate.
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Master P was 5 years and 9 months, a male child came with the mother for the
following complaints of speech was not adequate compared to his age, unable to
comprehend the simple instruction till one and half years. Gradually started his restlessness
behaviour and unable to complete the task assigned him due to poor attention and jumping
interest to another. Later he has not mingled with peers and others, and he has enjoyed to
play alone with the object. Similarly, he has talking while play alone and enjoying. He has
not repeated the functional words when others were taught. Later he could repeat the
functional words while alone which was taught by mother early. He has not maintained eye
contact with others, when the family members or others interacting with him. Rarely he has
maintaining eye contact when he wants his desire. He has showed the needs of object when
he required, and the parents also understand their child need. He has showed the anger,
repetitively claps his hand fast, closes his ear, makes sounds, or taps the table, floor, wall
that has reachable for his hand while changing his routine life. He has not able to understand
the simple comments and not respond to them. He has not able to know his name, and he has
not responded when others call his name. During his developmental stage, his head control
was attained at 6 months, sitting without support was attained at 10 months, started standing
alone at 1 year, walks alone at 1 year 6 months, and walks steps at 2 years 6 month which
shows delayed his gross motor skills. In fine motor skills, he was able to use proper pencil
holding at 1 year 6 months, scribbling at age of 2 years, copying circles and knowing rules of
the game till not achieved. which all the above delayed milestones were causative factors of
poor comprehension, delayed speech and behavioural issues. His mother observed that, he
was always moving here and there due to restlessness, he was not able to stay in one place,
even when he was in a social place. He used to run around a place and not get tired. He was
unable to complete the task, due to jumping his interest, so jumping another task after every
ten minutes. Suppose the mother or care givers was insisting to complete the task, he shows
irritation and followed by throwing away the things that are used for the task.

PAST HISTORY

There is no history of major physical or psychiatric illness reported by informant.

FAMILY HISTORY

Family genogram:
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33y 31y

5y9m

Master P was a single child living in a nuclear family with his parent. His father’s
named Mr. K, aged 33 years, and he runs own business. His personality was extrovert,
managing authoritative style of his family, and cordial to his family. There is no habit of any
addictive behaviour, no major physical or psychological illness reported except his speech
delay. The mother named Mrs. D, aged 31 years, works as a physiotherapist at a medical
hospital. Her personality was Neurotic with submissive type and managing cordial
relationships with family members and others. The child basic need doing by father and
grandparents in day time. There was no evidence of separation, divorce, dead, major
psychiatric or physical illness showed in family history.

PERSONAL HISTORY

Birth and early development

Prenatal history—The mother was conceived at the age of 25 and it was a planned
conception. She was unhappy during conception due to family issues. The mother was not
able to taking adequate food, resulting decreased weight and anaemic. Neonatal history--
He was a pre-term baby delivered at end of the 8 th months with caesarean baby due low
amniotic fluid in womb, and had jaundice after immediate birth. The birth weighed was 2.18
kilograms, birth cry absent, and kept in the ICU for another 3days and later discharged. There
was no history of high fever, breathing difficulties and seizure present during birth except
jaundice. Postnatal history: His developmental gross motor milestones show-- Master P
attained his neck control at 6 months, standing alone at 12 months, walk alone at 1 year 6
months, walk up and down the steps at 2 years 6 month. Which indicate that he was not
attained the developmental milestone appropriate to his age. Fine motor: He was able to
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grasping pencil attained at 1 year 6 months, scribbles at 2 years, coping circle and knowing
rules of games still not achieved. Which indicate that, he was inadequate in fine motor and
cognitive function. Language milestones: He was able to babbling attained at 6-months,
disyllable at 2 years 6 months, and he was not able to form a sentence, which indicate that,
delay in speech milestones. Social milestones: His social smile was attained at 6 months,
recognizes his mother at 1 year 6-months, identification of stranger at 1 years 6 month. He is
not socializing and not join the group play, which indicate that, his social milestone was
delayed to his age.
Behaviour during childhood:
There was habit of thumb sucking, bedwetting and sleep disturbance presented rarely.
The temper tantrums were severe and there is no history of conduct disturbance such as
fights, truancy, stealing etc. His relationship with parents was good.
Physical illnesses during childhood:
There was no history of physical illnesses during childhood such as epilepsy, high
fever, meningitis and encephalitis.
School history:
His schooling was started at age of 4 years, and it was an integrated education system.
Gradually he was started to disturbing other children, unable to continue the concentration,
not responding or comprehending the questions. The class teacher reported, He was not
communicating with others classmates, poor peer group adjustment, not mingle with other
classmates, frequent irregular in his school and unable to comprehend the class. The teacher
was advised consultation to his parents. The parent was discontinued his schooling.

Play history:
His play behaviour towards others was not adequate. He was not interest to play with
others, and his preferred to play alone, or he like to enjoy his own play. He was not following
the rules while playing because he was not understanding the comments and rules. He shows
excessive restlessness. His behaviour while playing in group situation was poor. His leisure
time activity was mobile and tv watching. He was extremely like in bike riding. Whenever
he saw the bike, he was forcing to sit on it and to enjoy.

TEMPERAMENT
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Activity level: He has hyper active and exhibiting excessive of anger comparing to other
children. His play activities were faster and jumping one to another without completion of
task.
Attention span & Persistence: He has able to gets attention but unable to persistent the
concentration due to restlessness and moving around.
Approach Withdrawal: He has not liked to mingle with others especially peer groups and
unable to cooperative during approach.
Adaptability: He has been difficulty to adapting to the environment easily.
Distractibility: He has been easily distracted due to unable to persistent the concentration.
Intensity of reaction: He has been showed hard reaction when not received his wish.
Threshold of responsiveness: He has unable bothered by ignorance, noise, and showed high
threshold.
Quality of mood: He has happy while individual play or alone, and also, he shows anger and
irritable due to his hyper and routine changes.
Rhythmicity: His hungry, sleep pattern and bowel movement has always variable and not
predictable.

BEHAVIOURAL OBSERVATION
General observation & Behaviour: He was not able to build up rapport, not maintain
adequate eye contact, unable to listen and comprehend the verbal instructions, and touch with
surroundings. Physical structure and appearance, dressing was good but he needs to lean
appropriate for his age. His behaviour towards other was poor because he was not likes to
mingle with peer or others. He makes himself alone in social situation and sometimes he feels
frightened to interact with others.
Psycho-Motor activity: His psychomotor activity has increased. He was very active during
interview and always shows restlessness. He uses the stereotype behaviour of repetitively
claps his hand fast, closes his ear, makes sounds, taps the table, floor or wall that has
reachable for his hand.
Talk: he was using echolalia or inappropriate speech. He was not maintaining conversation
to others or responding to comments.
Intelligence: Based on the clinical observation his intelligence is not adequate for his age.
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SUMMARY
Master p was 5 years 9-month, who lives in a nuclear family from the middle socio-
economic status, and living in urban region, come with his parents with the presenting
complains of unable to comprehend the instruction, restlessness and unable to complete the
task, not mingle with others, poor in eye contact, enjoying his own play, and unable to accept
his routine changes for the past 3 years. There was no history of past medical or psychiatric
issues reported. The mother was conceived at the age of 25 and it was a planned conception.
She was unhappy during conception due to family issues. The mother was not able to taking
adequate food, resulting decreased weight and anaemic. He was a pre-term baby with
caesarean bay delivered at end of the 8 th months due low amniotic fluid in womb. He had
jaundice after immediate birth. The birth weighed was 2.18 kilograms, birth cry absent, and
kept in the ICU for 3days after delivery. During his developmental stage, his head control
was attained at 6 months, sitting without support was attained at 10 months, started standing
alone at 1 year, walks alone at 1 year 6 months, and walks steps at 2 years 6 month. In fine
motor skills, he was able to use proper pencil holding at 1 year 6 months, scribbling at age of
2 years, copying circles and knowing rules of the game till not achieved. Which all the above
causative factors influence the poor comprehension, delayed speech and behavioural issues.

INITIAL FORMULATION
Master p was 5 years 9-month, who lives in a nuclear family from the middle socio-
economic status, and living in urban region, come with his parents. It was clinical interview
and behavioural observations that, the speech was not adequate compared to his age, unable
to form a sentence, unable to communicate verbally to show his need, unable to comprehend
the simple instruction such as when his family member call his name, he was not response to
it. He showed restlessness behaviour such as always roaming around the place even it’s an
unfamiliar place, and his attention was poor unable to complete the task that was assigned to
him, he eventually shifted into another task and, his was not mingled with peers and others.
He was like alone in social situation and sometimes he feels frightened to interact with
others. He was enjoying his own play with the object. He was talking while play alone and
enjoying. He was not repeated the functional words when others were taught. Later he could
repeat the functional words while alone which was taught by others. He was not maintaining
eye contact with others, when the family members or others interacting with him. He was
showing the needs of object when he required, and the parents also understand their child
need. He was showing the anger with repetitively claps his hand fast, closes his ear, makes
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sounds, or taps the table, floor, wall that was reachable for his hand while changing his
routine life. During the prenatal period, She unhappy during conception due to family issues.
The mother was not able to taking adequate food, resulting decreased weight and anaemic.
During the natal period: He was pre-term baby, caesarean delivered at end of the 8 th months
due low amniotic fluid in womb, and he had jaundice after immediate birth. The birth
weighed was 2.18 kilograms, birth cry absent, and kept in the ICU 3days. During post-natal
period: His developmental milestone of gross and fine motor skills, language, social and
cognitive milestones were delayed. The above all the aetiological factors were the bad
prognostics factors of this case. The following psychological assessment and test were taken
to assess his diagnosis, intelligence and severity.

PSYCHOLOGICAL ASSESSMENT AND REPORT

The observation of psychological assessment and its report mentioned.

VINELAND SOCIAL MATURITY SCALE (VSMS)

On VSMS reported that, his Social Age (SA) was 21 Months and his Social Quotient (SQ)
was 31, which declared that Delayed in Social Maturity with Severe level.
DEVELOPMENTAL SCREENING TEST (DST)
On Bharath Raj DST reported that His Developmental Age (DA) was 18 Months and His
Developmental Quotient (DQ) was 34, which declared that Delayed Developmental Maturity
with Severe level.
INDIAN SCALE FOR ASSESSMENT OF AUTISM (ISAA)
On ISAA shows that, He was scored 129, which declared that Childhood Autism with
moderate level.

PROVISIONAL DIAGNOSI

Based on the collection of case history and behaviour observation for both clinical interview
and psychological assessment further consideration of DSM-5 CRITERIA of 299.00 (F84.0)
AUTISM SPECTRUM DISORDER
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CASE 2
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SOCIO – DEMOGRAPHIC DATA

Name : Master. G
Date of birth & Age : 15/03/2018 & 6 years completed
Gender : Female
Education : LKG
Order of birth : First born
Family type : Join family
Socio economic status : Middle class
Language : Tamil
Religion : Hindu
Area of residence : Cuddalore
Rular/ Urban : Urban
Referred by : SRBS
Informant : Mother
Information : Reliable and adequate

PRESENTING COMPLAIN

 Drooling excessively
 Producing humming sound when she needs
 Speech was not adequate 4 years 6 months
 Comprehension was not appropriate
 Adamant while teaching 3 years
 Licking others and objects

HISTORY OF PRESENTING ILLNESS

MOOD OF ONSET : Insidious

COURSE OF ILLNESS : Continuous
PROGRESS : Improving
PERPETUATING FACTOR : Defect in 21st chromosome.
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Master G was 6 years old female child come with the mother for the complaints of
drooling excessively, producing humming sounds when she needs, speech not appropriate
compared to her age, and comprehension not adequate for past 4 years and 6 months. The
adamantine while she was learning, and licking others for the past 3 years reported. Mas. G
had excessive drooling while the age of 3 months. She was undergoing to physiotherapy for
controlling the drooling. Meanwhile mother was taking Mas. G to Sri Ramachandra Medical
College for further management for consultation during 4 months of age. They were
investigated and diagnosed as Ventricular Septal Defect (VSD) with Down Syndrome. The
doctors were counselled that, gradually closing her heart hole. Further they advised to
continue the medication along with physiotherapy. Master. G was not able to talk even single
words till 1 year and 6 months. She was expressing her needs by using humming sound to
showing the needs. While the mother was noticed her baby had speech delay, not
communicating verbally, not appropriate her comprehension, difficulty to cooperative while
learning, showing adamantine, and also, she was showing happy by using liking other.
Immediately the mother was taking her child for speech consultation at Dept of Speech and
Language Pathology, Aarupadai Veedu Medical College and Hospital, Puducherry. The
Speech therapy was started after the evaluation by the speech diagnostics. Another 1 year 6
months was received the speech therapy and discontinued due to Covid-Pandemic. Master.
G’s behavioural problems was increased during the pandemics. She was enjoying her play by
alone and mother was not adequately spending with the child. Gradually increased the
adamantine behaviour and licking to others and objects while from 2020. Mothers was
taking her child for continue the therapy after the pandemic to the Speech dept. The Speech
dept was referred to Clinical psychology OPD for psychological assessment and mental
health rehabilitation services along with speech therapy.

PAST HISTORY
Master G was diagnosed as Ventricular Septal Defect (VSD) with Down Syndrome at
4 months of age, conformed by Sri Ramachandra Medical College after proper medical
evaluation and testing. The doctor counselled, it was eventually closed, but still continued the
VSD. In the year of 2020, she was taking speech therapy at AVMC, continued 6 months
only and unable to continue the services due to covid pandemic. Mothers was taking her
child for continue again the speech therapy after the pandemic lockdown open. The Speech
department was referred to Clinical psychology OPD for further management along with
speech therapy.
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FAMILY HISTORY

Family genogram:

Grandfather Grandmother

F 43 M 37

6 years

Master G was a single child, living in a joint family with her parent and grandparent.
Her father’s name is Mr. S, aged 43 years, and he works at ship. His personality is extrovert,
managing authoritative style, and cordial to his family. There was no habit of any addictive
behaviour, no history of major physical or psychological illness reported. The mother’s name
is Mrs. A, aged 37 years, and she is a house wife. Her personality is Neurotic, submissive
type and managing cordial relationships with family members and others. Master G home
environment was good, and she likes to play with grandparents. There is no evidence of
separation, divorce, dead, major psychiatric or physical illness showed in family history.

PERSONAL HISTORY
Birth and early development
Prenatal history—The mother was conceived at the age of 31 years and it was a planned
conception. She was unhappy and stressful during conception due to husband away from
family for his employment, and heavy work pressure her school. There was no major
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complication during prenatal apart from above mentioned. Neonatal history-- She was a
full-term with caesarean baby due to over age of mother. The birth weighed was 3.200
kilograms, and birth cry present. There was no history of high fever, breathing difficulties
and seizure present during birth. Postnatal history: His developmental gross motor
milestones shows- Master G was attained neck control at 4 months, sits unsupported at 7
months, standing alone at 8 months, walk alone at 1year, which indicate that she was attained
appropriate gross motor milestone. Fine motor: She was able to grasping pencil attained at 7
months, scribbles at 2 years, and coping circle 3 years, which indicated that, she was
adequate in fine motor and cognitive function. Language milestones: She was able to
babbling attained at 10 months, disyllable at 1 year 6 months, and not able to form a
sentence, which indicate that, delayed speech milestones. Social milestones: Her social
smile was attained at 2 months, recognizes his mother at 3 months, identification of stranger
at 1 year 6 months, parallel play at 2 years 6 months, which indicate that, she was attained the
social milestones appropriate to her age.

Behaviour during childhood:

she was a habit of thumb sucking, bedwetting reported but it was not frequent.
There was no history of conduct disturbance such as fights, truancy, stealing etc.
Physical illnesses during childhood:
She was suffering from Ventricular Septal Defect (VSD) with Down Syndrome at 4
months of age. There was no other history of physical illnesses during childhood such as
epilepsy, high fever, meningitis and encephalitis reported.
School history:
She was started schooling at the age of 5 years, and currently studying a lower
kindergarten at integrated school. She was attending the regular school. Her school
performance was poor due to lack of understanding and inadequacy of speech. Attitude
towards her peers and teachers were not appropriate, not stay in one place, and grabbing the
other classmate’s things. There was no school phobia, avoidance, truancy, and adjustment
difficulties reported.
Play history:
She was interested to play with others and play behaviour was adequate. Even though
she was disturbing others due to adamantine and not waiting her turn to play. she was trying
to following the rules while playing, but unable to follow the instruction due to poor
comprehension. Her leisure activity was mobile watching and game.
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TEMPERAMENT
Activity level: she has faster her motor behaviour related to play and learning. Her play
activities were littler restless and jumping into another task within few minutes.
Attention span and persistence: She has abled to get attention but unable to persistent the
concentration due to moving around and unable to understand the comments.
Approach withdrawal: She has easily interacted with new environment and stranger. She
has eventually gone and roaming around the place due to unable to recognize the new or
strange. Hence no approach withdrawal found.
Adaptability: she has showed Initial reaction of withdrawal, and later she has easily adapted
the family, social and school.
Distractibility: She has easily distracted due to unable to persistent the concentration.
Intensity of reaction: she has to enjoy when received her wish or things.
Threshold of responsiveness: She has easily bothered by small noise or sounds, hence
indicate that low threshold.
Quality of mood: She has generally happy, while playing with other children, and enjoy the
play
Rhythmicity: Her hunger, sleep pattern and bowel movement has always predictable.

BEHAVIOURAL OBSERVATION
General observation & Behaviour: She was able to build up rapport partially, eye contact
maintained, and trying to listen and comprehend the verbal instructions. Her self-care was
under the mothers helps such as hair, dress, and other basic needs. Her physical structure and
appearance were appropriate. Her behaviour towards other was adequate and rarely shows
anger, and she was liking to mingle with peers or others. She was not able to comprehend
strange social situation.
Psycho-Motor activity: Her psychomotor activity was above average level. She was not able
to sit longer during interview.
Talk: She was able to express her thought to others by using humming sounds to showing the
things. At the same time, she was not able to made conversation due to inadequate speech.
Mood: She was generally happy to playing with other children and always laughing and
enjoy the play.
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Attention and Concentration: She was able to gets attention but unable to persistent the
concentration due to moving around and unable to understand the comments.
Intelligence: Based on the clinical observation and psychological assessment shows, her
intelligence was not adequate compared to her age.

SUMMARY
Master G is 6 years old female child, who lives in join family from the middle socio-
economic status, and living in urban region come with the mother for the following
complaints of drooling excessively, producing humming sounds when she needs, speech not
appropriate compared to her c age, and comprehension not adequate for past 4 years and 6
months. The adamantine while she was learning, and she liked to licking others for the past 3
years reported. Master G was diagnosed Ventricular Septal Defect (VSD) with Down
Syndrome while her age of 4 months at Sri Ramachandra Medical College. The doctor was
counselled to the parent that, the hole gradually closed in future, and mother reported the hole
was still in her heart. The mother was conceived at the age of 31 years and it was a planned
conception. She was unhappy and stressful during the pregnancy due to husband away from
family for his employment. She was experienced work pressure during for the first 6 month
of pregnancy. Master. G was a full-term baby delivered with caesarean baby due to over age
of mother. The birth weighed was 3.200 kilograms, and birth cry present. During her
developmental stage of gross motor, social and fine motor achieved appropriate to her age
except her language milestone, which few above causative factors influence the poor
comprehension, delayed speech and behavioural issues.

INITIAL FORMULATION
Master G is 6 years old female child, who lives in join family from the middle socio-
economic status, and living in urban region come with the mother for the complaints of
excessive drooling while 3 months of age. She was undergone the physiotherapy for
controlling the drooling. Meanwhile mother was taking her for further management for
consultation during 4 months of age. The paediatrician was investigated and diagnosed as
Ventricular Septal Defect (VSD) with Down Syndrome while her age of 4 months at Sri
Ramachandra Medical College. The doctors were counselled that, gradually closing her heart
hole. Further they advised to continue the medication along with physiotherapy. Master G
was not able to talk even single words till 1 year and 6 months. She was expressing her
needs by using humming sound with pointing the objects. The mother was started to noticed
 16

that, master G had speech delay, not communicating verbally and she was not able to
understand the comments. Later mother was observed, she was difficulty to cooperative
while learning and showing adamantine, not try to listen the lesson that the mother taught and
also, she was showing happy by using liking other. The mother was conceived at the age of
31 years. She was unhappy and stressful during conception due to husband away from
family for his employment and she was also experiencing the work pressure till first 6
months of conception. The baby was a full-term with caesarean baby due to over age of
mother. The birth weighed was 3.200 kilograms, and birth cry present. During her
developmental stage of gross motor, fine motor and social were achieved appropriate to her
age except language milestone. The few of above all the aetiological factors were the bad
prognostics factors of this case. The following psychological assessment observation were
taken to assess his diagnosis, intelligence and its severity.

PSYCHOLOGICAL ASSESSMENT AND REPORT

The behavioural observation of psychological assessment and its report mentioned.

VINELAND SOCIAL MATURITY SCALE (VSMS)

On VSMS reported that, her Social Age (SA) was 33 months and Social Quotient (SQ) was
45, which declared that Delayed in Social Maturity with moderate level.
DEVELOPMENTAL SCREENING TEST (DST)

On Bharath Raj DST reported that, her Developmental Age (DA) was 33 months and her
Developmental Quotient (DQ) was 46, which declared that Delayed Developmental Maturity
with moderate level.

SEGUIN FORM BOARD (SFB): she was not able to perform the child, due to difficulty to
identified the few shapes.

PROVISIONAL DIAGNOSIS

Based on the case history, behaviour and psychological assessment observation, the child
meets ICD-11 CRITERIA 6A00.1: Disorder of Intellectual Development (Moderate Level)
associated with Down syndrome (TRISOMY 21).
Based on the case history, behaviour and psychological assessment observation, the child
meets DSM-V CRITERIA F71: Intellectual Developmental Disorder (Moderate Level)
associated with Down syndrome (TRISOMY 21).
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CASE 3
 19

SOCIO – DEMOGRAPHIC DATA

Name : Mr. S
Date of birth & age : 10/11/2003 & 21 years
Gender : Male
Education qualification : ITI
Occupation : Unemployed
Order of birth : First born
Family type : Nuclear
Father occupation : Frommer
Mother occupation : Frommer
Socioeconomic status : Middle class
Place : Chengalpattu
Rural/urban : Urban
Language : Tamil
Religion : Hindu
Informant : self
Information : Reliable and adequate

PRESENTING COMPLAINS
 Excessive drinking 5 years
 Cannabis intake 3 years
 Tension
 Irritation 3month
 Head ache
 Decreased Sleep.
 Attempting suicide

HISTORY OF PRESENTING ILLNESS

MOOD OF ONSET : Insidious
COURSE OF ILLNESS : Continuous
PROGRESS : Improving
PERPETUATING FACTOR: Peer influence
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Mr. S is 21 years old came with the complains of excessive intake of alcohol. He was
started drinking in beer at the age of 15 years while his school period. It was started in social
drinking along with the influence of peer groups. It was weekly 4 beers, and gradually
increased the drinking from beer to hard liquor. Further he started to take additionally
cannabis at the age of 19 years during higher studies (ITI), and it was started occasionally. He
started an employability after completion of his ITI at the age of 20 years. Then he was
resigned while end of a month, due to stress and below average income from the present
occupation reported. Later he was joined another job as a CNC machine operator and
continued 3 months. Again, he resigned due to conflicts between co-workers. He had love
with a girl while his end of the higher studies. It will be continued till the recent
employment. The lover’s parent was controlled her, when they were knows their
relationships. It induced his anger outburst severely, with all those issues he was expressing
excessive tension, easily gets irritated, show the anger to the co-workers and higher officials,
friends and family members. Further he had experienced difficulty in sleep. Finally, he had
taken excessive alcohol and tried suicide by tie the rope around his neck to hanging, due to
fear he withdrawal the attempt. He was fired closet due to love failure, excessive depression,
he felt worthlessness and poor tolerance on next day morning. He was taken first aid at
private hospital for his physical complication after tried suicide. Then few days, he had
headache, sleep disturbance, preoccupation past life and forgetfulness of happy movement. It
was inducted to intake excessive alcohol and cannabis before admitted the deaddiction centre.

Negative history: Father has a history of alcohol usage.

Associated disturbances: The present illness has significantly impacted Mr. S personal,
interpersonal relationships, family (though he does it despite the decreased interest and
contentment from the same), self-confidence, enthusiasm, and optimism are also significantly
lower when compared to premorbid levels. With respect to biological functioning, sleep was
significantly impacted when he used to engage in compulsive drinking behaviour. No
changes in appetite, weight, libido, and sexual functioning are reported. The difficulties in
engaging regular activities of daily living are reported.

PAST HISTORY

He had a surgery in his vision due to visual difficulty during 8 years old. Apart from that,
there was not physical or psychiatric difficulties reported.
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FAMILY HISTORY
Family Genogram

45 years 40 years

20 years
18 years

Mr. S was a first baby, living in a nuclear family with his parent and brother. His
parent was a non-consanguineous marriage. His father’s named Mr. M, aged 45 years, and he
was a former. His personality is extrovert, managing authoritative style and cordial of his
family. Family history of his father had an alcohol usage. Father had history of brain tumour
and convulsion. The mother named Mrs. D, aged 40 years, and she was helping in the
forming work with her husband. Her personality is Neurotic with submissive type and
managing cordial relationships with family members and others. His brother named Mr. A,
aged 18 years, discontinued ITI currently working as a delivery man. There was no evidence
of separation, divorce, dead, major psychiatric or physical illness showed in family history.

PERSONAL HISTORY

Birth and Early Development:

According to his response, his prenatal, perinatal and post-natal were normal. His
developmental milestones were met appropriately.
Behaviour during Childhood:
He was no history of sleep disturbances, thumb sucking, nail biting, temper tantrums,
bedwetting, stammering, tics, and mannerisms reported during his childhood. There was no
history of conduct disturbances in the form of frequent fights, truancy, stealing, lying, and
gang activities. His relationships with parents, siblings, and peers were adequate.
Physical Illness during Childhood:
There was no history of any psychiatric or physical illnesses were reported except eye
sight difficulty at the age of 8 years and get operated for it.
 22

School history:
He started schooling at the age of 3 years, completed schooling at the age of 18 years
and continued his diploma in ITI in industrial training institutes at the age of 20. During
collage period he started to take cannabis (at the age of 19). in industrial training institutes
and he finishes his collage at the age of 20. During collage period he started to take cannabis
(at the age of 19). His scholastic performance was average, regular in his education and
attitudes towards peers and teachers were adequate. There is no history of learning
difficulties, educational phobia, or avoidance, truancy, adjustment difficulties, and
extracurricular activities.
Occupation history:
He started his work at the age of 21 years, in a private company and continued 1
month only. He was resigned due to heavy work pressure and the salary was low. Later he
was joined another job as a CNC machine operator and continued few months. Again, he
resigned due to conflicts between coworkers.
Marital history: He is unmarried.
Sexual History: He gets his sexual knowledge from friends, and mobile. He reported that
that he has masturbation behaviour occurs rarely.
Use and Abuse of alcohol, tobacco, and drugs: He was started drinking at the age of 15
years when he was in school period due the influence of social drinking with peer. He
consumed liquid 4 times a week, the drinking intake was gradually increased and he started
to take additionally cannabis at the age of 19 years old, and it was occasionally.

PREMORBID PERSONALITY

Attitudes to others in social, family and sexual relationships: He was attached to his
family and friends with no notable unhealthy dependence patterns. He reported to prefer
being a follower, rather than a leader within his peer group and most times being a
submissive to others. He is adjustable and independent in his relationship.
Attitudes to self: He was energetic and social person. He reported his shortcomings to
primarily entail being submissive to peer pressure, in most circumstances. With respect to
interpersonal relationships, he described himself as outgoing, confident and as someone who
prefers company to solidarity. He trusts others and has substantial, meaningful relationships
with his family and friends.
 23

Moral and religious attitudes and standards: his Moral and religious attitudes and
standards has been adequate.

Mood: He reported that, his mood was happy and controlled his feelings of irritated and
angry. There were no mood swings reported.
Leisure activities and interests: In his free time used to play cricket, volleyball and kabaddi.
There was no interest to watching move, reading books, and listening music reported.
Fantasy life: his fantasy life has not been explored.
Reaction pattern to stress: he was not able to tolerate frustrations, losses interest,
disappointments and he easily get angry to closed one.
Biological functions and habits: He reported that, His sleep was not adequate and not
appropriate in his appetite, due to social drinking and drug usage (cannabis).

MENTAL STATUS EXAMINATION

General observation & behaviour: He was in touch with his surroundings, relaxed, and
oriented his problems. He looked clean, dressed appropriately and well-groomed. His
behaviour towards others was appropriate. He was conscious of his present condition, he
could pay attention be held. He was cooperative, established adequate rapport, and
maintained adequate eye contact.
Psychomotor Activity: His psychomotor behaviour was appropriate. No presence of tics,
apathy, lethargy or motor coordination were noted.
Talk: His speech was intact in terms of tone, volume, tempo, prosody, relevance, flow, rate
and coherence observed.
Thought: His thought shows no deviations in thoughts of stream, form or possession of
thoughts. He recognises negative thoughts as his own and produced by one’s self. The
content of thought is primarily about negative outcomes of events, thereby creating the
element of dominant preoccupation for the client.
Mood: Subjectively, His verbal and nonverbal behaviour reflects an anxious mood and he
said he was sad because he misses his family. Objectively, the quality of emotion was sad.
Perception: He had no experience of sensory or perceptual distortions, psychotic
phenomena, depersonalisation, derealisation or any other such related phenomena.

Cognitive functions
 24

Attention and Concentration: His attention and concentration were intact. He was able to
perform the serial subtraction and list all the months and days backwards.
Orientation: He was oriented to time, place of situation, and person, and can sense and
comprehend the passage of time.

Memory: His memory was intact. He performed digit forward and digit backwards
adequately, resulting in adequate immediate memory. Recent memory was tested by asking
him what he had last dinner and breakfast in the preceding 24 hours. Hence adequate recent
memory. Remote memory was assessed by asking for his date of birth, and the name of the
school he studied, resulting in adequate remote memory.
General Information: His general knowledge was sufficient and accurate. He was able to
name the Prime Minister of the country, 5 states' names and the chief minister. Hence, he
provided adequate general information.
Intelligence: His global impression based on academic history and progression, as well as the
general provision of information and responses, indicates average levels of intelligence.
Abstract Ability: His ability of abstraction was intact. He was asked to state a proverb and
explain its meaning as well as to draw similarities and differences between the objects, both
of which were also executed successfully.
Judgement: His personal, social and test judgement was intact.
Insight: He was recorded to depict “Intellectual Insight” (6)

SUMMARY

Mr. S was a born in first baby, nuclear family from the middle socio-economic status,
and living in urban region came with the complains of excessive intake of excessive drinking
for 5 years, Cannabis intake for 3 years, tension, irritation, head ache, decreased sleep for 3
month and attempting hanging. He was fired closet due to love failure, excessive depression,
he felt worthlessness and poor tolerance on next day morning of hanging. He was taken first
aid at private hospital tried suicide. He had a surgery in his vision due to visual difficulty
during 8 years old. Apart from that, there was not physical or psychiatric difficulties
reported. He started schooling at the age of 3 years, completed schooling at the age of 18
years and continued his diploma in ITI in industrial training institutes at the age of 20. During
his collage period, he started to take cannabis (at the age of 19). His scholastic performance
was average, regular in his education and attitudes towards peers and teachers were adequate.
 25

There is no history of learning difficulties, educational phobia, or avoidance, truancy,

adjustment difficulties, and extracurricular activities. He started his work at the age of 21
years, in a private company and continued 1 month only. He was resigned due to heavy
work pressure and the salary was low. Later he was joined another job as a CNC machine
operator and continued few months. Again, he resigned due to conflicts between co-workers.
Further the clinical interview and behavioural observations reported that general observation
& behaviour was adequate. His psycho motor behaviour was appropriate, and his speech was
intact. Thought shows no deviations in thoughts of stream, form and content of thought. His
mood was sad and he was no experience of sensory or perception. His attention and
concentration were intact, he was oriented to time, place of situation and person. His memory
was intact and average levels of intelligence. His ability of abstraction was intact, and he was
recorded to depict “Intellectual Insight” (6), which shows all essential features of the
problems.

INITIAL FORMULATION

Mr. S was a first baby with nuclear family from middle socio-economic status, and
living in urban region came with the complains of excessive intake of alcohol. He was started
drinking in beer at the age of 15 years while his school period. It was started in social
drinking along with the influence of peer groups. It was weekly 4 beers, and gradually
increased the drinking from beer to hard liquor. Further he started to take additionally
cannabis at the age of 19 years during higher studies (ITI), and it was started occasionally. He
started an employability after completion of his ITI at the age of 20 years. Then he was
resigned while end of a month, due to stress and below average income from the present
occupation reported. Later he was joined another job as a CNC machine operator and
continued 3 months. Again, he resigned due to conflicts between co-workers. He had love
with a girl while his end of the higher studies. It has continued till the recent employment.
The lover’s parent was controlled her, when they were knowing their relationships. It
induced his anger outburst severely, with all those issues he was expressing excessive
tension, easily gets irritated, show the anger to the co-workers and higher officials, friends
and family members. Further he had experienced difficulty in sleep. Finally, he had taken
excessive alcohol and tried suicide by tie the rope around his neck to hanging, due to fear he
withdrawal the attempt. He was fired closet due to love failure, excessive depression, he felt
 26

worthlessness and poor tolerance on next day morning. He was taken first aid at private
hospital for his physical complication after tried suicide. Then few days, he had headache,
sleep disturbance, preoccupation past life and forgetfulness of happy movement. It was
inducted to intake excessive alcohol and cannabis before admitted the de-addiction centre.
There was no complication during his childhood. There was no history of any psychiatric or
physical illnesses were reported except eye sight difficulty at the age of 8 years and get
operated for it. his premorbid personality of Attitudes to others in social, family and sexual
relationship reported, he was prefer being a follower, rather than a leader within his peer
group and most times being a submissive to others. He was adjustable and independent in his
relationship. Attitudes to self was energetic and social person. He was entail being
submissive to peer pressure, in most circumstances. There was no interest to watching move,
reading books, and listening music reported. His reaction pattern to stress was he was not
able to tolerate frustrations, losses interest, disappointments and he easily get angry to closed
one. His biological functions and habits where sleep was not adequate and not appropriate in
his appetite, due to social drinking and drug usage (cannabis). Further the clinical interview
and behavioural observations shows no difficulties. The above all the aetiological factors
were the bad prognostics factors of this case. The following psychological assessment
observation were taken to assess his diagnosis, intelligence and its severity.

PSYCHOLOGICAL ASSESSMENT AND REPORT

Eysenck personality questionnaire (EPQ)

On EPQ shows that, he was scored 7 on psychoticism, neuroticism scored 17, Extraversion
scored 14, and lie score was 6 which indicate he has Neuroticism.
Alcohol use disorder identification test (ADUIT)
on ADUIT revealed that, his score was 10, which indicate he is in harmful zone of alcohol
use.
Neo five-factor inventory (NEO-FFI)
on NEO-FFI reported that, neuroticism score was 11 which indicate he has neurotic feature,
extraversion score was 23 which indicate no extraversion, openness score was 12 which
indicate he has openness feature, agreeableness score was 28 which indicate average level of
agreeableness, and conscientiousness score was 30 which indicate average level of
conscientiousness.
Anxiety depression stress scale (ADSS)
 27

on ADSS scored that, his anxiety score was 3 which indicate he falls in anxiety, in depression
score was 5 which indicate below average level of depression, and stress score was 8 which
indicate average level of stress.

PROVISIONAL DIAGNOSIS

According to case history and mental state examination the patient meets DSM-V criteria of
F10.20 Moderate Alcohol use disorder.