CASE NO 2

IDENTIFICATION DATA:

A 30 year old unmarried female, 12th dropout, resident of Qamarwari, Unemployed belonging to
lower socio economic status residing with her mother and her married sister, brought by sister
with chief complaints of:
1)Suspiciousness
2)Self muttering
3)Aggression

Total Duration of Illness: 15 years

INFORMANT:

38 Year old female, elder sister of the patient currently residing with the patient since 2018 to
look after her sister and mother (both psychiatric patients) has enough mental capacity to
understand the nature of illness, giving adequate history, Hence reliable.

Onset: Insidious
Course: Continous
Progress: Deteriorating
Predisposing factor: Family history of psychiatric illness in mother
Precipitating factor: Death of father
Perpetuating factor: not known.

HISTORY OF PRESENT ILLNESS:

The patient was in her usual state of health 15 years back when the family noticed that the patient
is getting suspicious towards everything. She would usually abuse the family members saying
that they are making some plans to harm her. In an incident she went to a peer and told him that
her father that her father looks at her ina wrong manner when her uncle scolded her, she then
even blamed them of molestation. The patient later grew suspicious towards the neighbours and
her relatives that they have sent spies to follow her and they have send helicopter to keep a watch
on her. The patient would mutter to herself and laugh with herself and when alone she would spit
around, soil her bedding with curries and sauce. She would stare at things and then would tie up
any things and then throw them away. If she gets to have money she spends all of them on junk
foods. She would at time eat 15 to 16 eggs in a single day. She would often accuse relatives and
brother in law for inappropriately touching her. Many a times she created rukus while travelling
in local bus and spit on many males and abuses them verbally for touching her. She would get
aggressive without any provocation and would verbally abuse her family members and even spit
on them. She would curse the prominent leaders of Kashmir almost everyday shouting loudly in
the lawn. The patient would take care of her hygiene herself. The patient currently often repeats
the past incidences and then relate them with some other meanings example in an incidence, she
told her mother that school teachers scolded her because her mother would have told them to do
so.
Currently the patient is brought to the hospital by elder sister with request for a medical
certificate so that the pension of her late father which s currently released in the name of their
mother that should be released in the name of patient.
NEGATIVE HISTORY:-
No history suggestive of significant:
Recurrent intrusive thoughts
Ritualistic behavior
Abnormal body movements
Urinary incontinence
Low mood

Birth and Developmental History:-

The patient is a product of non-consanguineous marriage, and born out of Full
Term Normal Delivery. There were no complications during pre and post natal
period. The patient achieved her normal developmental milestones at appropriate
times, there were no developmental delays

Family and social relationships: The patient is close to her mother, but she feels that her
mother is favouring her sister more. She started having grudges towards her sister since
childhood as she felt she was avoided and scolded often. According to patient, her sister was
respected more and was considered sober. They were often compared and she often craved for
love of her parents.

Childhood History: : All developmental milestones were achieved on time. No childhood

disorders were reported. Family atmosphere was congenial.

Educational History: The patient has studied upto 11th and she failed her 12th exams after which
she lost interest in her studies. She was an average student in her school time, and did not have
any significant troubles in her interactions with other kids. She was not particularly ambitious in
her academic goals - she just wanted to be a graduate.
Play History : The patient wasn’t very active in outdoor play activities. However,
if and when persuaded by her classmates, friends or teachers she would
participate in group play activities.
Puberty:- The patient reached menarche at the age of 16, to which she did not
react very well, as she did not have an amiable relationship with her mother- so
she was bereft of her support , and hence failed to seek her counsel or
reassurance, instead she turned to her friends, who told her strange myths about
menstruation. She used to be extremely uncomfortable and anxious during her
monthly cycles.
Menstrual and Obstetric history- Her menstrual cycle has been fairly regular
since menarche.Each cycle lasts for about 3-5 days. She has two children - each
of whom were born through full term normal delivery .She did not experience
any complications during her pregnancy.
Occupational History: The patient is a housewife - she has never held a job.
Sexual and marital history: denies any sexual history.
Forensic History: No significant forensic history

Premorbid Personality
Interpersonal relationship: The patient was reserved and reticent pre-morbidly.
She had a calm and composed temperament. She was not very expressive in her
interpersonal interactions, She would always put the needs of others ahead of
herself. She was very helpful and caring in her interpersonal interactions.
Use of leisure time: The patient liked doing household chores, she particularly
enjoyed cooking.
Predominant Mood:- Her predominant mood was stable, but pessimistic and
prone to anxiety. She had a despondent reaction to life’s stressful events
Attitude to self and others: The patient was a timid person and didn’t think very
highly of herself. She harboured feelings of inferiority and insecurity , and was
therefore usually guarded and cautious in her relationships with others. She
found it quite difficult to share her feelings with others.
Attitude to work and responsibilities: The patient has an easy going attitude to
work and family responsibilities. She takes her responsibilities in her stride and
enjoyed doing the household work , and taking care of her children.
Religious beliefs and moral attitudes: The patient was born in a sunni Muslim
family. She observes her religious obligations dutifully and rarely falters .She has
never gone through any religious crises. Her beliefs and ideas about religion are
rather passive.
Fantasy Life:- The patient reports that she indulged in daydreaming often , as it
served to be a means of an escape from her life situations. She dreamt of
having a happy and stable family life.
Habit:-No particular food fads or any idiosyncrasies could be elicited. The patient
was rather laid back, however in times of stress she became easily worked up
and hurried.
Alcohol and Substance history- No significant substance use history was found

MENTAL STATUS EXAMINATION

General appearance and behavior.
Appearance: Medium built and height, well kempt. The patient is dressed as per
culture and climate. She looks appropriate to her age. Her finger nails are clean ,

but uncut. She makes and maintains eye contact.Rapport establishment took
some time as the patient is pre-morbidly reticent.
Attitude towards the examiner: The patient was hesitant and anxious at first ,and it took
considerable amount of time, effort and encouragement from her sister for her to speak up and
share her problem
Comprehension;- Intact
Gait and posture:- Normal, the patient was sitting with her back slightly hunched.
Psychomotor activity: normal, the patient was sitting in a slouched posture and
was relatively still throughout the session
Social Manner- The patient averts her gaze and makes eye contact hesitantly .
She is ill at ease .
Rapport :- Rapport was established with considerable effort. An empathic
relationship was developed with the patient.
Speech:
Rate and Quality:- Speech was spontaneous, its Rate was increased.
Volume and Tone:- Low volume and pitch
Flow and Rhythm:- Hesitant
Mood and Affect
Mood: The patient verbalises her mood as ‘kabhi Theek , kabhi kharab
Affect: Dysphoric
Thought:-
Stream and Form:- Continuous /Normal - The thought processes are relevant to
the questions asked. No evidence of loosening of associations, tangentiality ,
circumstantiality, perseveration or verbigeration was found
Content
Perception:-The patient denies any abnormal perception. No evidence found for
the presence of hallucinations, Illusions and misinterpretations, depersonalisation/
derealisation.
Cognition:-
Consciousness and orientation- The patient is fully aware and conscious, and is
oriented to time/place/ person.
Attention & concentration:- Patient could easily repeat the digits recited to her
for forward and backward repetition. She correctly subtracted the number 7
from 100, back wards upto the 3 steps.
Memory
Immediate memory: Intact - The patient recollected the items (ball, stone ,
fan) she was asked to remember after 5 minutes of conversation
Recent memory: Intact - The patient could recall the breakfast she had and the
dinner she had the previous night-this information was corroborated with her
husband who confirmed its veracity.
Remote memory: Intact The patient remembered the year of her high
school graduation and the date of birth of her children
Intelligence: The patient has adequate knowledge as per her social and cultural
context.Inspite of her educational qualification, she doesn’t display much interest
in any specific kind or academic, intellectual or recreational pursuit
As per the clinical judgement of the patient’s performance in information,
comprehension, Arithmetic& Vocabulary- the patient appears to be of average
level of intelligence
Abstract thinking: Intact (E) What does this mean, jesi karni wesi bharni
(Pt) aisa kaam waisa nateeja’
(E) table aur kursi me ek jesa kya hai? (P) “dono cheezain hain lakdi ki
Her abstract thinking on the basis of proverbs, similarities and differences was
found found to be of concrete type.
Insight: Grade 4,

Judgement:
Test judgement: Intact. (E) What would you do if you see a letter lying on the
ground and you see it has address also mentioned in.(P) ‘post office mein duungi
Social Judgement: Intact (E) asked what would you do if your brother fell ill?
(P) ‘check up karungi, dawai laungi’
Personal Judgement: (E) asked what will you do when you go back home from
hospital (P) ‘Koshish karungi theek karne ki apni zindagi ko”

TESTS ADMINISTRERED AND THEIR RATIONALE:

 MILLION’S CLINICAL MULTI AXIAL INVENTORY (MCMI-III)

 DRAW A PERSON TEST (DAPT)

 RORSCHACH INKBLOT TEST ( RIBT)

MILLION’S CLINICAL MULTI AXIAL INVENTORY (MCMI)

Patients scores on the response scales are as follows :-

THE DISCLOSURE INDEX ( 95)

The scores obtained by the patient in this index falls within the expected range and hence it
connotes that she was inclined to be frank and self-revealing.

THE DESIRABILITY INDEX (55)

The patients score on this dimension indicates that she has not consciously and deliberately
concealed any aspect of his psychological and interpersonal difficulties.

DEBASEMENT INDEX (67)

The patient’s score on this dimension indicate thatshe hasn’t deprecated or devalued oneself
by presenting more troublesome emotional and personal difficulties.

 Clinical personality patterns

The clinical personality pattern syndrome indicates in patient are-

Schizoid (96) High scores indicate that she is apathetic, distant, and social .The findings may
imply incapacity to experience deep pleasure or pain

 Clinical syndrome
The clinical syndrome pattern indicated in patient are -

Anxiety (98):- She is typically tense, indecisive and restless,& there is generalized state of
tension.

Post traumatic stress disorder (81):- Patient with score in this dimension may indicate that
she may have experienced an event that involved a threat to their life and reacted to it with
intense fear or feelings of helplessness, images and emotions associated with trauma
resulting in distressing recollection and nightmares.

Dysthymia (76):-High score connote that she may be inclined towards feeling sad, discouraged,
and guilty. Also the patient may also experience low self-esteem, self deprecatory, pessimistic
outlook towards future; she is likely to exhibit social withdrawal, fatigue and marked loss of
interest in pleasurable activities

DRAW A PERSON TEST (DAPT)

On DAPT protocols the findings reveals that she is having schizoid traits , maternal
dependency , somatic preoccupation , emphasis on possession and social prestige ,self
centered, obsessive compulsive tendencies , contemptuous attitude , tendency to think in
terms of derisive social stereotypes ,self centered , anxiety and overt aggression

RORSCHACH INKBLOT TEST ( RIBT)

Positive findings on Rorschach include:

R=16, L=4.3, EB= 1:0.5, EA=1.5, AFR=0.45 ,XA%= 0.62 , WDA%=0.6 , X-%=0.37, X+% =0.5,

XU%=0.12 ,W:D:Dd =4:11:1 ,W:M= 4:1, Zd= -3.5, S-CON = 2 , DEPI =2 , HVI =0 , PTI =3 ,

CDI= 3 , OBS =0 ,Egocentricity index = 0.43, Sum human content =3, Isolation index =0.06

On Rorschach protocols, the findings on the dimensions of- Controls and Stress Tolerance,
Situationally Related Stress, Affect, Information Processing, Cognitive Mediation, Ideation, Self
Perception and Interpersonal Perception- are as follows:

Controls and Stress Tolerance

Results indicate that she is more vulnerable to becoming disorganized by many of the natural
everyday stresses of living in a complex society& may function most effectively in environment that
are well structured and reasonably free of ambiguity .

Situationally related stress

It can be assumed that some situational stress is present and the stress tolerance of the person is
lower than usual and typical capacities for control may be less sturdy than is customary.

Affect

Results are indicative of the presence of an avoidant –introversive style exists .It can be assumed that
the person usually is disposed to keep feelings at a more peripheral level during problem solving and
decision making . However, presence of the avoidant style can reduce the overall effectiveness of this
ideational orientation.

Also, test results indicate that the person is less interested in or less willing to process, emotional
stimuli. This finding is most common among those with an avoidant style and tends to depict their
preference to limit complexity. It should not necessarily be considered as a liability, but instead, simply
reflects a preference to be less involved with emotional stimuli

Information Processing

The test results are indicative of an Avoidant style .People with this style tends to economize and
avoid complexity & she may be very economical in the processing effort.
Also test indicates that the person is striving to accomplish more than may be reasonable in light of
current functional capacities .If this tendency occurs in everyday behaviors, the probability of failure to
achieve objectives is increased and the consequent impact of those failures can often include the
experience of frustration.

Further test reveals that the subject scans hastily and haphazardly and often may neglect critical bits or
cues that exist in a stimulus field

Cognitive Mediation

The findings signal the likelihood towards a serious meditational impairment. Also results indicate
an avoidant style & are being maintained by reality distortions

Ideation

Results signify that the individual is an avoidant – introversive. Avoidant – introversive are ideationally
oriented , but they differ substantially from the true introversive .Although they are prone to delay
decisions while considering various options , the domination of the avoidant style usually causes the
process to be less thorough and their conceptual activities are likely to be marked by much more
simplicity .They prefer to keep feelings at a more peripheral level during problem solving and decision
making , but they are more vulnerable to emotional intrusions in their thinking when confronted with
complexity or ambiguity .

Also, it is probable that the person tends to react quickly to reduce the irritations created by the
intrusions of peripheral thoughts.

Self Perception

As per the test results the egocentricity index falls within the average range, hence it points
towards the possibility that the patient is no more or less self involved than most others.

It is presumed that the self image of the person is based more on experience than imagination; it
simply suggests that social interactions have probably contributed significantly to formulations
regarding the self.

Interpersonal Perception and Behavior

Results suggest that the individual is not interested in others as much as most other people.
Test summary
 On MCMI protocol, the clinical personality pattern indicates that patient is having
schizoid personality Traits & the clinical syndrome pattern indicates that she is having
anxiety along with PTSD features .

 On DAPT protocol, the findings reveal that she is having schizoid traits along with
contemptuous attitude and tendency to think in terms of derisive social stereotypes.
Findings also reveal that she is self centered and is having anxiety and overt
aggression.

 RORSCHACH protocol shows stress tolerance of the person is lower than usual.

 Presence of an avoidant –introversive style.

 She is very economical in the processing effort.

 She scans hastily and haphazardly and often may neglect critical bits or cues that exist
in a stimulus field.

 She is also having a serious meditational impairment, which is being maintained by reality
distortions.

 Patient tends to react quickly to reduce the irritations created by the intrusions of
peripheral thoughts.

 Patient is not interested in others as much as most other people.

Diagnostic Formulation:
A 30 year old unmarried female, 12th dropout, resident of Qamarwari, Unemployed belonging to
lower socio economic status residing with her mother and her married sister, brought by sister
with chief complaints of Suspiciousness, Self muttering and Aggression with MSE showing
Young female ,Medium built and height, well kempt. The patient is dressed as per culture and
climate with no evidence found for the presence of hallucinations, Illusions and
misinterpretations, depersonalisation/derealisation with intact judgement with grade 4 insight.

Diagnosis:
1) Schizoaffective disorder
2) Bpad with psychotic features.