Akal College of Nursing, Baru Sahib

Psychiatry (Mental Health) Nursing

Case Presentation
on
BPAD current episode Depression
without psychotic symptoms

Submitted to: Submitted by:

Mr. Joseph Jeganathan Ms. Komal Rana
Assistant Professor M. Sc. (N) 2nd Year
MHN Dept. MHN Dept.
BS17MHNS008

Submitted on:
12/12/18

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 HISTORY TAKING
1. SOCIO DEMOGRAPHIC DATA
A patient named Mr. Balbir Singh, married male, 70 years old son of S. Iqbal Singh resident of
Kapurthala. He belongs to Sikhism. He studies up to 10 th class and he can speak/write/read
Punjabi, Hindi and little English. He has worked in the Border Security Forces before getting
admitted to the hospital; presently not working, family income was not elicited. The source and
reason for referral is not known. Reason of consultation/ admission is decreased talk, staying
quiet, decreased sleep, has become slow in doing activities from 1.5 months. The information
gathered from patient, patient’s care giver (wife) of the patient and is adequate and reliable.
II. PRESENTING COMPLAINTS:
Source of information: Patient & care giver (wife) of the patient.
List of complaints:
According to the patient:
Mansik rog hai 40 years
Chakkar aate hain
Beech beech mein bhul jata hun 4-5 years
According to the care giver:
Chup rehte hain
Baat nahi karte hain 1.5 months
Raat ko sote bhi nahi hain
Saare kaam dheere dheere karte hain
III. HISTORY OF PRESENT ILLNESS:
List of complaints: According to the records:
Psychiatric: Not talking to wife and staying quiet, forgets things even the activities of daily
living from last 1.5 months. The onset is sub acute and course is episodic, no precipitating,
aggravating and reducing factors are present.
Biological: Decreased sleep, maintaining self care only when asked to do so. The onset is sub
acute and course is episodic, no precipitating, aggravating and reducing factors are present.
Socio- occupational: He was taking care of the domestic animals but has left everything because
he started forgetting things. The onset is sub acute and course is episodic, no precipitating,
aggravating and reducing factors are present.

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Others: Not present.
Duration of illness:
Mode of onset: Sub- acute
Course: Continuous
Precipitating factors: Not present
Description: Mr. Balbir Singh, 70 year old patient was admitted in Dr. Vidyasagar Institute of
Mental Health on 3rd Dec. 2018 when he started sleeping less, he would go to bed at usual time
but when his wife would wake up at night for any reason she would find the patient lying in bed
with eyes open. When his wife will ask why he is not sleeping he would tell nothing. This
behavior got increased with time till the present and the patient sleeps only for 2-4 hours every
night and seemed tired in the morning.
His wife Ms. Vimal Kaur also said that Mr. Balbir Singh stopped talking to her about 1.5 months
ago. Whenever she would talk to him he would give short replies or sometimes only one word
answers. He would never initiate the conversation. She also said that he would pace inside house
and sometimes say “Meri zindagi narak ban gayi hai, sab kuch khrab ho gya hai because he has
become old and could not do anything and his memory has also become bad as he forgets things.
Ms. Vimal Kaur also told that he also forgets to do activities of daily living when he is alone and
would do the activities when told multiple times to do so. He has stopped taking care of the
domestic animals earlier he was doing that. She also told that he also forgets whether he has
taken food or not and would ask for food again.
Treatment history:
Name of Medication Duration Dose Frequency Side effects Prognosis
1. Tab. Quitipine 15 years 50 mg TDS Dizziness, weakness 20%
2. Tab. Lorazepam 15 years 2 mg BD Blurred vision 20%
3. Tab. Risperidone + THP 13 years 2 mg OD Dizziness 20%
4. Tab. Donepezil + 9 years 100 mg BD Loss of appetite 20%
Memantice
ECT ECT was given to patient when he was previously admitted but no
record is available.
Psychosocial intervention
Vocational Training
Religious/ Homeopathy/ Not given to the patients
Ayurvedic

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Negative history: There is no history of trauma, fever, headache, vomiting, confusion, no
significant physical illness like hypertension and diabetes and other major psychiatric illnesses
(Organic, Substance abuse) are not present in the patient.
IV. PAST HISTORY:
The history of the patient was given by the patient’s wife. According to her the patient Mr.
Balbir Singh had same episode when he was about 16-18 years old after failing in 10 th class
examination, this was told to her by her mother in law but she didn’t know the exact details. He
also had an episode 5 years after their marriage when he was posted in Srinagar. She didn’t
remember the exact details of the episode. But said that he allegedly slaughtered chicken in a
place of worship after which he got mental illness and was admitted in the hospital of Srinagar
for treatment of mental illness. He was discharged after 15 days. When he was in BSF and got
the episodes he would be sent back to home and after getting better he would refuse to take
medications saying he don’t need it and it’s not necessary.
He was sent back home after one year from work due to mental illness, he had decreased sleep,
increased talking, tall claims like “main hi hun aur koi nahi hai,” increased grooming than usual
and buy clothing at higher rate more than usual, he would become angry easily and became more
religious and would do “path” for hours. He was taken to local hospital and treatment was taken
and improvement was seen within 15-20 days. After that he had similar episodes every 1-2 years.
He was also admitted in Dr. Vidyasagar Institute of Mental Health and was also given ECT. He
left his job 17 years back and is taking medications regularly but with the compliance to the
medications but he had 2-3 similar episodes in the past 17 years.

Psychiatric illness: The patient was admitted two times earlier but no record of the previous
admission was elicited from the patient and care giver also.
Medical illness: There is no significant history of any medical illness.

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 V. FAMILY HISTORY:
Genogram:

S. Name of family Age & Relationship with Education Occupation Health

No. members Sex patient status
1. S. Balbir Singh 45/M Patient self Matriculation Not working BPAD
2. Ms. Vimal Kaur 67/F Wife No formal Home maker Healthy
education
Details of family functioning
1. Type of family : Nuclear
2. SES : Middle
3. Leadership pattern : Not elicited
4. Role functions : Not elicited
5. Communication within the family and others: Good
6. Child rearing practices : Satisfactory
7. Interpersonal relationships : Satisfactory
8. Social position : Middle class family
9. Social support system : Available
History of illness in family:
Psychiatric: There is no history of any psychiatric illness in the family.
Medical: There is no medical history in the family.
VI. PERSONAL HISTORY:
Birth and development : Not elicited
Childhood health : Not elicited
Behavioral and emotional problems: Not elicited

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Home atmosphere during childhood: Satisfactory
Home atmosphere during adolescence: Satisfactory
Parental lack: No
Anomalous family situation: No
Educational history
Age of beginning : 5 years
Age of finishing : 16 years.
Relationship with teachers : Satisfactory
Relationship with schoolmates: Satisfactory
Position in class : Middle
Special abilities : No
Active participation in games : Not elicited
Occupational history : He had worked in BSF for approximately 30 years and after that
he was sent home because of mental illness.
Sexual history: Not elicited
Marital history:
Year of marriage : They was married in 1967
Spouse : She is 67 years old, has no formal education, home maker
Marital relationship : Satisfactory
Sexual relationships : Satisfactory
Children : They have three children; 2 girls and one boy.
VII. PREMORBID PERSONALITY:
i. Social relations: Patient had good social relationships with family members and neighbors.
ii. Intellectual activities: Not elicited.
iii. Mood: Cheerful and optimistic
iv. Character:
a. Attitude to work and responsibility: He had positive attitude towards work and
responsibilities, he would take given responsibility seriously.
b. Interpersonal relationships: He had good interpersonal relationship with family
members and neighbors.
c. Standards in moral, religious, social and health matters: Not elicited

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 d. Energy and initiative: He would take initiative in doing household work and looking
after the domestic animals after leaving the job in BSF.
v. Fantasy life: Not elicited
VIII. HABITS: The eating habits, sleeping pattern and excretory functions of the patient were
normal. He never took alcohol. Self medication history was not present.

IMPRESSION: The patient grew up in a village. He started sleeping less; he would sleep only
for 2-4 hours every night and seemed tired in the morning. He stopped talking to her about 1.5
months ago. He would give short replies or sometimes only one word answers whenever his wife
talked with him and would never initiate the conversation. He would say “Meri zindagi narak
ban gayi hai, sab kuch khrab ho gya hai because he has become old and could not do anything
and his memory has also become bad as he forgets things. He also forgets to do activities of daily
living when he is alone and would do the activities when asked to do so. He has stopped taking
care of the domestic sometimes he also forgets whether he has taken food or not and would ask
for food again. He has previous history of depression and manic episodes. Because of his mental
illness he left his job. There is history of non compliance of medications. But now he is on
regular medications since last 15 years. This time because of the problems; decreased sleep, slow
movements, forgetfulness, less or no talk, impairment in activities of daily living and self care
his wife got him admitted in the hospital on 3/12/18.

PHYSICAL EXAMINATION
HEAD TO TOE EXAMINATION:
1. General examination:
Height : 5’ 5”
Weight : 66 kg
Body odor : Present
Activity : Decreased PMA
Appearance : Well groomed and hygienic
Orientation : Not oriented to time, but oriented to place and person
Speech : Appropriate but volume is low
Consciousness : Conscious

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2. Vital signs:
Temperature : 98.60
Pulse : 82 beats/minute
Respiration : 20 breaths/minute
Blood Pressure : Not measured (Apparatus was not available)
3. Integumentary system:
Color : Fair complexion
Odor : Present of perspiration
Lesions : Not present
Skin turgor : Normal
Hydration : Hydrated
4. Skull:
Size : Normocephalic
Symmetry : Symmetrical
5. Scalp & Hairs:
Dandruff : Not checked because he was wearing turban
Color : White
Distribution : Not checked because of turban
Texture : Normal
6. Nails:
Colors : Pale
Nail plate : Intact
Capillary refill : > 2 seconds
Other symptoms : Not present
7. Abdomen : Not done
8. Upper extremities:
Joints : Normal ROM but activity was slow
Edema : Absent
Pain : Absent
Peripheral pulse : 72 b/ minute
9. Lower extremities:

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 Joint : Normal ROM but activity was slow
Edema : Not present
Pain : Absent
10. Genitourinary system:
Bladder frequency: 4-5 times/day
Bowel frequency : 1 time/ day
Any infection : Absent
NEUROLOGICAL EXAMINATION
A. General appearance: The gestures, posture, were normal, gait of the patient was slow.
Cleanliness was maintained and had taken bath. Eye to eye contact was maintain and was not
sustained. No odd movements and oddities in behavior observed were smiling without any
reason, self muttering, and self mumbling.
B. Level of consciousness:
Glasgow coma scale:
1. Eye opening :4
2. Verbal response :5
3. Motor response :6
Total score : 15
According to the Glasgow coma scale the patient is fully conscious.
C. Cranial Nerve examination:
1. Olfactory nerve: Not done
2. Optic Nerve: (Asked to read the newspaper)
The patient was not able to read properly the headings and the content of the newspaper. The
visual acquity isnot normal blurring of vision was present. The peripheral vision is also
normal.
3. Occulomotor, trochlear and abducens nerve: (Showed pen and asked to follow pen
movement without moving head)
The eyes movement of the patient was congruent to the movement of the pen.
4. Facial Nerve: (Asked patient to raise eyebrow, smile and blow cheeks)
The patient raised eyebrow, smiled and blew the cheeks normally. No facial paralysis, bell’s
paralysis and muscle weakness was present.

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5. Glossopharangeal and vagus nerve: (Asked to swallow)
The swallowing reflex is normal, no dysphagia was present. Gag reflex was also normal.
6. Accessory Nerve: (Asked to shrug shoulders against resistance)
The patient shrugged shoulders normally with adequate strength.
7. Hypoglossal Nerve: (Asked to protrude tongue and move side to side)
The tongue movement of the patient was normal as he was able to move the tongue from side
to side.

MENTAL STATUS EXAMINATION

1 GENERAL APPEARANCE & BEHAVIOR:
Mr. Balbir Singh is a average heighted and thin married male age 70 years weight is 60 kgs and
height is 5’5” and look’s one’s age, the dress which worn by the patient was appropriate to age,
season, setting, were not clean and neat, properly worn, the colors of the dress were dull. The
patient was properly dressed and was adequately clean appeared neat and bathed. The odor of the
perspiration was present. The patient had sad and worried and sometimes blunt facial
expressions. The eye contact was maintained but not sustained.
1.2 Behavior and Psychomotor activity (PMA):
Gait : Slow
Handshake: Done and it was weak
Abnormal movements: Absent.
Posture: Stooped
Rate of movements: Decreased
Co-ordination of movements: Normal
Psychomotor Activity- The psychomotor activity of the patient was decrease and most of the
times he kept sleeping in his bed and sometimes come out in sun to sit. Ability to follow
commands/ requests present, no compulsions was present. Catatonic phenomena such as
excitement, stupor, rigidity, posturing, tics, poise, mutism, etc. were not present.
1.3 Attitude towards examiner:
Attitude towards the examiner was co-operative and friendly. Rapport was established.
1.4 Level of Consciousness: Conscious
The patient is a male appearing his stated age, wearing a kurta, pyjama, sweater and
slippers. He is Sikh so shave was not done and have a neat and clean appearance. He walks with

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slow pace and sits with his shoulder shrugged, giving the stooped appearance. The patient had
sad, worried and sometimes blunt facial expression, gives slow and late response but co
operative in nature. He maintains eye contact but is not sustained.
2. EMOTIONAL EXPRESSION (Mood and Affect)
Mood:
Nurse: “Aaj aapka mann kaisa hai?”
Patient: “Thik hai” (with sad and worried facial expression)
Affect:
Appropriateness of affect : Appropriate and congruous
Intensity & Range of affect : dull
Stability of affect : Stable
Attitude toward nurse : Friendly but sometimes withdrawn, he was co-operative
Quality or feelings : Sadness, depressed and detached
Anxiety Level : Mild
Subjectively he reports feeling good. But objectively he appears sad, worried and tensed.
His emotional expression is stable, not of full range, and appropriate to content.
3. SPEECH:
Quantity : Responds only to questions; talks less, Reaction time is
delayed and increased but answers are relevant.
Intensity of Volume : Nurse: “Kaise ho aap”
Pateint: “Thik hun”
The tone of patient’s response is decreased.
Tempo/Rate of Speech (WPM) : Slow
Flow of Speech : Long pauses
Fluency and Rhythm : Clear, and relevant sometimes slurred.
Clarity : Clear, sometimes not understandable due to low tone.
Liveliness : Dull and monotonus
He responds only to questions and doesn’t provide any information by his own. Volume
is low. Rhythm and expressive intonation are clear but sometimes slurred and not
understandable. Speech is understandable, but sometimes not understandable.
4. THOUGHT:

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3.1 Thought Process or Form: Relevant, flow of thoughts is slow but coherent.
His thoughts are generally logical and goal directed, he is not circumstantial, launching
into emotional accounts of relevant ideas and gives relevant details. There is no evidence of
flight of ideas, and circumstantiality.
3.2 Disorders of Stream of thought-
 Disorders of tempo: Sometimes thought retardation is present because he responds very
late. There is evidence of ideas of hopelessness because he says, “sab khatam ho gya hai,
dimaag thik nahi hai mera, mansik rog ho gya hai.” Sometimes he also says, “garib aadmi
hun, sab paise khatam ho gye hain kya bataun aapko” so ideas of poverty is also present.
 Disorders of continuity: Sometimes thought block is present because he stops when
answering a question and takes time to respond and the examiner has to remind him what
he was talking about.
3.3 Disorders of the Possession of thought or control of thinking:
Q. “Kya aapko koi aisi vichaar ya photo dimag mein bar bar aate hain aur jate nahi?”
A. “Nahi”
Q. “Kya aapko lagta hai ki aapke dimaag mein koi apne vicharr daal rha hai?”
A. “Nahi.”
Q. “Kya aapko aisa lagta hai ki koi aapke vichaar aapke dimaag se nikal rha hai?”
A. “Nahi.”
Q. “Kya aapko aisa lagta hai ke aapke vichaar TV ya fir radio pr aate hain?”
A. “Nahi”
3.4 Disorders of Content: Delusions:
Q. “Kya aapko lagta hai ki koi aapke khilaaf sajish kar rha hai?”
A. “Nahi.”
Q. “Kya aapko lagta hai k log aapke bare mein batein krte hain?”
A. “Nahi”
Q. “Kya aapko lagta hai ke aapke pass koi aisi taakat hai jo kisi aur ke pass nahi hai?”
A. “Nahi”
Q. “Kya aapko aisa lagta hai ke aapke sharer ka koi aang kisi ne nikaal diya hai?”
A. “Nahi”
Q. “Kya aapko aisa lagta hai ke koi aapko dhokha de rha hai?”

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A. “Nahi.”
Q. “Kya aapko aisa lagta hai ke aapke sharer par kisi ne vaash kiya hai?”
A. “Nahi”
Suicidality and Homicidality
1. Suicidality
Q. “Kya aapke mann mein marne ke vichaar aate hain?”
A. “Nahi”
2. Homicidality
Q. “Kya aapke mann mein kisiko marne ya nuksaan phunchane ke vichaar aate hain?”
A. “Nahi”
He is having ideas of hopelessness and poverty. There is no evidence of delusion of
reference, nihilistic, control. There is no evidence of thought withdrawal, thought insertion and
broadcasting. There are no current suicidal or homicidal thoughts, intent, or plan.
5. PERCEPTION:
Hallucinations
Q. “Kya aapko koi aisi aawazein sunai deti hain jo kisi aur ko nhai sunai deti hain?”
A. “Nahi.”
Q. “Kya aapko aisi cheezein dikhai deti hain jo kisi aur ko nahi dikhai deti hain?”
A. “Nahi.”
Q. “Kya aapko aisi smell aati hai jo kisi aur ko nahi aati?”
A. “Nahi”
Illusions:
Q. “Kya aapko aas pass ki cheezein jo asli mein kuch aur hai aapko kuch aur dikhai deti hai jaise
ki rassi saanp.?
A. “Nahi”
Depersonalization/ Derealization:
Q. “Kya aap jante ho aap kon ho?”
A. “Balbir Singh.”
Q. “Kya aapko lagta hai ke duniya khatam hone wali hai?”
A. “Nahi.”
6. COGNITIVE FUNCTIONS:

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6.1 Alertness: Mr. Balbir was fully awake and alert and responsive.
6.2 Orientation:
Q. Aapka pura naam kya hai?
A. Balbir Singh
Q. Aaj kya tareek hai?
A. Pta nahi
Q. Abi kon sa mahina chal rha hai
A. November
Q. Abi saal kon sa hai?
A. 2007
Q. Abhi din hai ya raat?
A. Din hai
Q. Kya aap bta sakte ho ki ye kon si jagah hai?
A. Mental Hospital.
Q. Kya aap bta skte ho wok on hai (pointed towards his wife)?
A. Meri wife hai. (told correct)
Inference: He was not oriented to time but oriented to place and person.
6.3 Attention & Concentration:
6.2.1 The digit span test- Forward
Nurse Patient’s response
1, 3, 5 1, 3, 5
4, 2, 7, 9 4, 2, 7, 9
6, 8, 3, 5, 1 6, 8……..
The digit span test- Backward
Nurse Patient’s response
1, 2, 3 3, 2, 1
7, 3, 9, 1 7, 1, 9…….
6.2.2. Serial subtraction
Nurse Patient’s response
100- 7 93………
40 – 3 37, 35, 34, 29

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20 – 1 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, 2, 1
6.2.3 Days or months forward to backward:
Q. Kya aap mujhe mahino ke naam bta sakte ho?
A. January , February, March, April, May, June, July, August, September, October, November,
December
Q. Kya aap in naam ko ulta bol skte ho?
A. December, November, October, September, August, July, June, April, March, February,
January.
Q. Kya aap mujhe hafte ke dino ke naam bta skte ho?
A. Somvaar, Mangalvaar, Budhvaar, Veervar, Shukarvaar, Shanivaar, Ravivaar.
Q. Kya aap in naam ko ulta bol sakte ho?

A. Ravivaar, Shanivaar, Shukarvaar, Veervar, Mangalvaar, Budhvaar, Somvaar.

Inference: The attention can be aroused but can’t be sustained. Concentration was average.
6.4 Memory:
6.3.1 Immediate memory-
Q. Mera naam Komal hai, main aapse 5 min bd puchungi fr mujhe btana dobara mera naam kya
hai?
A. Komal (After 5 minutes but took some time to remember but told correct)
6.3.2 Recent memory
Q. Kya aap mujhe bta sakte ho aapne subh kya khaya?
A. Khichdi. (Confirmed with the wife)
6.3.3 Remote memory
Q. “Bharat kab aazad hua tha?”
A. “1947 mein”
Q. “Aapki shadi kab hui thi.”
A. “1967.” (Cross checked with his wife, it was correct.)
Inference: The immediate, recent and remote memory was intact.
6.5 Intelligence:
6.5.1 Information and Vocabulary:
Q. “Kya aap bta sakte ho hmare desh ka pradhan mantri kon hai?”
A. “Modi.”

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Q. “Koi si 5 nadiyon ke naam batao?”
A. “Beas, Jhelum, Chenab, Raavi”
Q. “Koi se 5 shehro ke naam btao”
A. “Amritsar, Ajanala, Barnala.”
Q. India ki capital kya hai?
A. Delhi
Q. Acha capital of Punjab?
A. Chandigarh
Q. Chandigarh aur kis state ki capital hai?
A. Haryana
Inference: General information is adequate.
6.5.2 Vocabulary: Could not be elicited because he was giving short answers and one word
replies.
6.5.3 Comprehension:
Q. “Jab aapko thand lgegi to kya kroge?”
A. “Garam kapde pehnenge sweater, jacket.”
Q. “Hmein buri sangati se dur kyun rehna chahiye?”
A. “Nahi to hum bure ho jayenge.”
Inference: Comprehension is good.
6.5.4 Arithmetic ability: He was not able to do sums on copy but when I asked him that you
have 50 toffees and you gave 5 toffees to your wife how many left.
A. 45
Q. You are going in a bus and have 20 rupees you gave 15 rupees as bus fare how many rupees
left?
A. 5
Q. You have 65 apples and I gave you 21 more how many apples you have?
A. Not answered.
Inference: Arithmetic is average.
6.5.5Abstraction:
A. Similarities:
Q. “Kya aap bta sakte ho ke pen aur pencil mein kya same hai?”

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A. Not answered.
Q. “Seb aur Santre mein kya same hai hai?”
A. “Seb mein piece nhi hote santre mein piece hote hain.”
Q. “Table aur chair mein kya same hai?”
A. Not answered
B. Differences:
Q. “Kya aap bta sakte ho ke pen aur pencil m kya alag hai?”
A. Not answered
Q. “Seb aur santre mein kya alag hai?”
A. Not answered
Q. “Table aur chair m kya alag hai.”
A. Not answered.
C. Proverbs:
Q. “Andhe ki laathi.”
A. Not answered
Q. “Naach na jane aangan tedha.”
A. Not answered
Inference: Abstraction is impaired.
6.6 Judgment:
6.6.1 Personal:
Q. “Aap jab hospital se chale jaoge to kya kroge?”
A. “Kuch nhi.”
6.6.2 Social:
Q. “Agar aap kisi shadi m jaaoge to kaise kapde pehnoge?”
A. “Ache kapde pehnenge shadi wale.”
6.6.3 Test:
a) Fire problem: “Agar aap ek kamre mein ho aur wahan par aag lg jaye to kya karoge?”
A. “Bhaag jaunga.”
b) Letter problem: “Agar aap kahin ja rahe ho aur aapko ek chithi milti hai jiske upar address
likha ho aur stamp lgi hui ho to aap uss chithi ka kya kroge?”
A. “Post kar dunga.”

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Inference: Personal /Test judgment and social judgment are intact.
6.7 Insight:
c) Fully realizes his illness, and feels he requires treatment. (Insight is present)

Summary of the Findings: Mr. Balbir Singh, 70 years old married male patient admitted in the
family ward of Dr. Vidyasagar Institute of Mental Health has ideas of hopelessness and ideas of
poverty, he was not oriented to time but was oriented to place and person he has intact
immediate, recent and remote memory, general information is adequate, comprehension is good,
impaired judgment, attention can be aroused but can’t be sustained and concentration was poor.
Patient’s arithmetic abilities were average, his abstraction was also poor, his personal judgment
is impaired, and test and social judgment were intact.

DSM IV:
Axis I: Provided information about clinical disorders. Any mental health conditions, other
than personality disorders or mental retardation, would have been included here.
In Mr. Balbir Singh Mood disorder is present i.e. BPAD with current episode Depression.
Axis II: Provided information about personality disorders and mental retardation.
In Mr. Balbir Singh his premorbid personality he was cheerful and responsible.
Axis III: Provided information about any medical conditions that were present which might
impact the patient's mental disorder or its management.
In Mr. Balbir Singh there is no medical condition is present which might impact the
patient’s mental disorder.
Axis IV: was used to describe psychosocial and environmental factors affecting the person.
In Mr. Balbir Singh there is no psychosocial and environmental factors are present which
can affect him.
Axis V: was a rating scale called the Global Assessment of Functioning; the GAF went from 0 to
100 and provided a way to summarize in a single number just how well the person was
functioning overall. A general outline of this scale would be as follows:
100: No symptoms
90: Minimal symptoms with good functioning
80: Transient symptoms that are expected reactions to psychosocial stressors
70: Mild symptoms or some difficulty in social occupational or school functioning

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60: Moderate symptoms or moderate difficulty in social, occupation or school functioning
50: Serious symptoms or any serious impairment in social occupational or school functioning
40: Some impairment in reality testing or communication or major impairment in several areas
such as work or school, family relations, judgment, thinking or mood
30: Behavior is considerably influenced by delusions or hallucinations or serious impairment in
communication or judgment or inability to function in almost all areas
20: Some danger of hurting self or others or occasionally fails to maintain minimal personal
hygiene or gross impairment in communication
10: Persistent danger of severely hurting self or others or persistent inability to maintain minimal
personal hygiene or serious suicidal act with clear expectation of death

In Mr. Balbir Singh Score is 40: Some impairment in reality testing or communication or
major impairment in several areas such as work or school, family relations, judgment,
thinking or mood.

Provisional diagnosis: BPAD current episode Depression without psychotic symptoms.

Description of Disease
Bipolar Affective Disorder

Introduction:
Bipolar affective disorder (BPAD) is a psychological illness that involves severe mood swings.
These mood swings take the form of depression or mania and may last for several months at a
time.
During the time of depression patients often have great sadness, guilt, no appetite, poor sleep and
cannot enjoy themselves. Mania is the opposite of this with patients experiencing erratic and
excited behavior.
During mania patients often have increased libido, need less sleep, have excessive energy and
can sometimes engage in risky behavior (such as gambling excessively) or can even become
violent.
Hypomania is a less extreme form of mania and while the symptoms are similar they are less
intense. Some patients may also have a mixed episode that involves the symptoms of both a
manic and depressed episode during a short period of time (less than 1 week).
There are 3 recognized types of BPAD:
 Type I: Patients have very high manic periods and depressive episodes.

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 Type II: Patients have severe depressions but only mild manic (hypomanic) episodes.
 Type III: Called Cyclothymic disorder, the patient has only mild depression and mild
mania.
There is also a type called Rapid Cycling Bipolar Affective Disorder. With Rapid Cycling the
patient changes from depression to manic at least 4 times a year and episodes of depression and
mania are short.
Statistics on Bipolar Affective Disorder (Manic Depression)
There is a 2.5% chance of developing BPAD type I & II during your lifetime. The chance for
combined BPAD and Cyclothymic disorder is reported as 5.2%. No racial differences exist.
Males are more likely to develop BPAD than females.
ICD-10 classification of BPAD:
F31.0: Bipolar affective disorder, current episode hypomania.
F31.1: Bipolar affective disorder, current episode mania without psychotic symptoms.
F31.2: Bipolar affective disorder, current episode mania with psychotic symptoms.
F31.3: Bipolar affective disorder, current episode mild or moderate depression.
F31.4: Bipolar affective disorder, current episode severe depression without psychotic
symptoms.
F31.5: Bipolar affective disorder, current episode severe depression with psychotic symptoms.
F31.6: Bipolar affective disorder, current episode mixed.
Depression: While all the person feel sad, moody or low from time to time, some people
experience these feelings intensely, for long periods of time (weeks, months or even years) and
sometimes without any apparent reason. Depression is more than just a low mood – it's a serious
condition that affects the physical and mental health.
Definition: Depression is a mood disorder characterized by persistently low mood and a feeling
of sadness and loss of interest for minimum of 2 weeks. It is a persistent problem, not a passing
one, lasting on average 6 to 8 months.

Types of Depressive disorder:

Major Depressive Disorder (MDD): It is characterized by depressed mood or loss of interest or

pleasure in usual activities.

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Dysthymic disorder: Dysthymia now known as persistent depressive disorder refers to a type of
chronic depression present for more days than not for at least two years. It can be mild, moderate, or
severe.
Premenstrual dysphoric disorder: Among the most common symptoms of premenstrual
syndrome (PMS) are irritability, fatigue, anxiety, moodiness, bloating, increased appetite, food
cravings, aches, and breast tenderness. Premenstrual dysphoric disorder (PMDD) produces
similar symptoms, but those related to mood are more pronounced.
Substance induced mood disorder (Depression): The depressed mood associated with
substance induced mood disorder is considered to be the direct result of physiological effects of a
substance and causes clinically significant distress or impairment in social, occupational or other
important areas of functioning.
Risk factors:

Book Picture Patient Picture

 Having a first-degree relative, such as a
parent or sibling, with bipolar disorder
 Periods of high stress, such as the death of a
loved one or other traumatic event
 Social class
 Race and culture
 Drug or alcohol abuse
 Personality
 Childhood trauma
 Substance abuse
 Chronic pain syndrome
 Some prescribed drugs
Causes:

Book Picture Patient Picture

 Precise cause unknown
 Age and gender
 Marital status

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 Seasonality
 Genetics
 Biochemical and psychological factors
 Environmental
 Hypothyroidism

Psychopathology:

Precipitating event
(A loss- Real or Perceived)

Predisposing factors
Family history of depression
Genetic influence:
Possible biochemical alteration

Past experiences: Anger turned inward on the ego

Learned helplessness--- numerous
failures
Object loss in infancy
Defect in cognitive development
Existing Condition: Inadequate coping skills
Lack of adequate support system
Possible neuroendocrine disturbances
Medication side effects
Other physiological conditions

Cognitive appraisal

Primary

(Threat to, or loss of, self esteem)

Secondary

Because of weal ego strength, patient is unable to use coping mechanisms effectively.

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 Defense mechanisms utilized: denial, regression, repression, suppression, displacement,
isolation.

Quality of response

Adaptive Maladaptive

Uncomplicated Delayed Exaggerate

bereavement inhibited grief distorted grief

Denial of loss Clinical depression

Sign and symptoms: Depression can affect men, women, and children differently.
Book Picture Patient Picture
Symptoms of depression in men may include:
 Mood: anger, aggressiveness, irritability,
anxiousness, restlessness
 Emotional: feeling empty, sad, hopeless

 Behavioral: loss of interest, no longer finding

pleasure in favorite activities, feeling tired
easily, thoughts of suicide, drinking
excessively, using drugs, engaging in high-risk
activities

 Sexual: reduced sexual desire, lack of sexual

performance

 Cognitive: inability to concentrate, difficulty

completing tasks, delayed responses during
conversations

 Sleep: insomnia, restless sleep, excessive

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 sleepiness, not sleeping through the night

 Physical: fatigue, pains, headache, digestive

problems

Symptoms of depression in women may

include:
 Mood: irritability
 Emotional: feeling sad or empty, anxious or
hopeless
 Behavioral: loss of interest in activities,
withdrawing from social engagements,
thoughts of suicide
 Cognitive: thinking or talking more slowly
 Sleep: difficulty sleeping through the night,
waking early, sleeping too much
 Physical: decreased energy, greater fatigue,
changes in appetite, weight changes, aches,
pain, headaches, increased cramps
Symptoms of depression in children may
include:
 Mood: irritability, anger, mood swings,
crying
 Emotional: feelings of incompetence (e.g. “I
can’t do anything right”) or despair, crying,
intense sadness
 Behavioral: getting into trouble at school or
refusing to go to school, avoiding friends or
siblings, thoughts of death or suicide
 Cognitive: difficulty concentrating, decline
in school performance, changes in grades
 Sleep: difficulty sleeping or sleeping too

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 much
 Physical: loss of energy, digestive problems,
changes in appetite, weight loss or gain

Diagnostic criteria for depression according to ICD- 10:

Requires 4 or more (of 10) symptoms present for at least 2 weeks.
Symptoms must include ≥ 2 of:
 Depressed mood
 Anhedonia
 Energy loss
Symptoms include:
1. Depressed mood
2. Loss of interest and enjoyment
3. Reduced energy leading to:
 Increased fatigability
 Diminished activity
4. Reduced concentration and attention
5. Reduced self-esteem and self confidence
6. Ideas of guilt and unworthiness
7. Bleak and pessimistic views of the future
8. Ideas or acts of:
 Self-harm
 Suicide
9. Disturbed sleep
10. Diminished appetite

Management of Depression:

Book Picture Patient Picture

Assessment:
 History collection

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 Physical examination
 Mental status examination
 Neurological examination
 Laboratory investigations

Medical management:
Antidepressants are drugs available on
prescription from a doctor. Drugs come into
use for moderate to severe depression, but
are not recommended for children, and will
be prescribed only with caution for
adolescents.
A number of classes of medication are
available in the treatment of depression:
 Selective serotonin reuptake inhibitors
(SSRIs)
 Monoamine oxidase inhibitors (MAOIs)
 Tricyclic antidepressants
 Atypical antidepressants
 Selective serotonin and norepinephrine
reuptake inhibitors (SNRI)

Psychotherapy:
Therapy can be given in a variety of formats,
including CBT and Interpersonal therapy:
 Individual: This therapy involves only the
patient and the therapist.
 Group: Two or more patients may
participate in therapy at the same time.
Patients are able to share experiences and

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 learn that others feel the same way and have
had the same experiences.
 Marital/couples: This type of therapy
helps spouses and partners understand why
their loved one has depression, what
changes in communication and behaviors
can help, and what they can do to cope.
 Family: Because family is a key part of the
team that helps people with depression get
better, it is sometimes helpful for family
members to understand what their loved one
is going through, how they themselves can
cope, and what they can do to help.
Electroconvulsive Therapy

NURSING ASSESSEMENT:
1. History collection
2. Physical Examination
3. Neurological Examination
4. Mental Status Examination
5. Problem Identification according to Peplau’s Theory
NURSING DIAGNOSIS
1. High risk for self directed violence related to hopelessness as evidenced by verbalization
of the patient.
2. Impaired communication related to hopelessness as evidenced by change in pattern of
interaction as reported by family member.
3. Hopelessness related to depression as evidenced by the verbalization.
4. Chronic low self esteem related to biochemical imbalances as evidenced by expression of
hopelessness.
5. Hopelessness related to disturbed thought as evidenced by improper hygiene.
6. Disturbed sleeping pattern related to unrealistic thinking as evidenced by verbal report.

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 7. Self care deficit (brushing, bathing, grooming) related to forgetfulness as evidenced by
report of the family member.

Assessment Nursing Planning Implementation Evaluation

(Orientation Phase) Diagnosis (Identification Phase) (Exploitation Phase)
Cognitive impairment High risk for self Goal setting was done Carried out plans
is experienced by the directed violence along with the patient. mutually agreed with the
client. related to  Assess the suicidal client.
Discussed with the hopelessness as thoughts in client.  Assessed the suicidal
client regarding evidenced by  Provide safe thoughts of the clients.
suicidal thought, verbalization of environment to the  Given positive
intension or plan. the patient. client. feedback for
 Intervene if the client appropriate behavior.
exhibits any behavior  Provided the client
that is unsafe. with the opportunities
 Use matter of fact for release of tension
approach. that are safe.
 Give positive
feedback for
appropriate behavior.
 Provide the client with
opportunities for
release of tension that
are safe.
Gives one word or Impaired Goal setting was done Carried out the plans
short replies to communication along with the patient. mutually agreed with the
questions. related to  Assess the client.
Discussed with the hopelessness as communication  Assessed the
client about the evidenced by pattern of the client. communication pattern
expression of feelings. change in pattern  Spend time with the of the client.
of interaction as client even when he is  Spent time with the

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 reported by unable to respond or client when he is
family member. takes time to respond. unable to respond.
 Provide enough time  Provided enough time
to answer the question. to answer the
questions.
Ideas of Hopelessness Goal setting was done Carried out the plans
hopelessness are related to along with the patient. mutually agreed with the
present in the client. depression as  Encourage the client patient.
Discussed the reason evidenced by the to express his feelings  Encouraged the client
of hopelessness with verbalization. verbally. to express his feelings
the patient.  Teach the client verbally
problem solving  Encouraged the client
process. to continue his
 Encourage the client medication seven after
to continue the the discharge.
medications even after
the discharge.
Feelings of Chronic low self Goal setting was done Carried out the plans
hopelessness is present esteem related to along with the patient. mutually agreed with the
in the patient biochemical  Encourage the client client.
Discussed about the imbalances as to become involved  Encouraged the client
reason of evidenced by with the staff and other to get involved with the
hopelessnesss in the expression of clients in interactions. other clients in
patient. hopelessness  Give the client interactions.
positive feedback for  Given the client
completion of tasks. positive feedback when
 Involve the client in he interacted with the
activities that are one client’s care giver.
recreational.  Involved the client in
 Explore the personal some activity therapy
strengths of the clients. e.g. match the following

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Prognosis of the patient: Mr. Balbir Singh 70 year old married male admitted in family ward of
Dr. Vidya Sagar Institute of Mental Health with diagnosis of BPAD. The symptoms of the
patient during the time of admission were decreased talk, decreased sleep, forgetfulness after
admission in the hospital in the first 1-2 days he didn’t talk to anybody but after that he started
talking when approached, started getting involved in activity therapy, ventilated his feelings of
hopelessness and he is on treatment of BPAD from last 15 years. His condition was getting better
after admission in the hospital.

Future care/ Follow up: Mr. Balbir Singh and his wife Ms. Vimal Kaur were advised about the
importance of compliance to treatment and regular intake of medicines. Ms. Vimal Kaur was
also advised and counseled about the condition of the patient. She was told to regularly attend
the follow as it is very important in improvement of the condition of the patient.

Summary: My patient named Mr. Balbir Singh 70 year old married male was admitted in the
family ward of the Dr. Vidyasagar Institute of Mental Health on 3rd Dec. 2018 with the
complaints of decreased talk, decreased sleep, forgetfulness, and slowness in doing activities of
daily living from last 1.5 months. So his wife got him admitted in the hospital. He is also a
known case of BPAD from last 30 years. He is taking treatment for the same. Compliance to
treatment is present.

The Mental status examination of the patient showed that he has ideas of hopelessness and ideas
of poverty, he was not oriented to time but was oriented to place and person he has intact
immediate, recent and remote memory, general information is adequate, comprehension is good,
impaired judgment, attention can be aroused but can’t be sustained and concentration was poor.
Patient’s arithmetic abilities were average, his abstraction was also poor, his personal judgment
is impaired, and test and social judgment were intact.

Conclusion: I have taken a case Mr. Balbir Singh of BPAD with current episode depression
without psychotic symptoms. The case presentation includes:

 History Collection
 Physical Examination
 Neurological Examination
 Mental Status Examination

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 Description of disease
 Nursing Care Plan
 Progress Notes
 Summary
 Conclusion
 References

References:
Book reference:
1. Townsend MC. Depression. Psychiatric Mental Health Nursing. Published by Jaypee. 7th
edition, page no. 555-569
2. Sreevani R. Depression. A guide to Mental Health & Psychiatry Nursing. Published by
Jaypee. 4th edition. Page no. 208- 210
3. Schultz JM, Videbeck SL, A textbook of Psychiatric Nursing Care Plans, 6th Edition,
Published by Elseiver, Page No. 88, 39, 355, 171

Net reference:
1. http://www.brisbanenorthphn.org.au/content/Document/Pathways/LINK%20A_ICD_10.pdf
2. https://www.beyondblue.org.au/the-facts/depression
3. https://www.verywellmind.com/common-types-of-depression-1067313
4. https://www.verywellmind.com/five-axes-of-the-dsm-iv-multi-axial-system-1067053

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