CASE I

Demographics of the patient: the patient is 28 year old unmarried female. She is resident of

Srinagar. She has studied up to class 10 th and is currently unemployed. She lives in a nuclear family of

three members of middle socio-economic status.

Information was taken from the patient and her father who is 55 year old who lives with patient is very

close to her since childhood and is concerned about her. There has been complete consistency in

information and no information gap was in history .Both the patient’s and informant’s version were

same.

Hence information is reliable and adequate

Chief complaints:

 Excessive concern for cleanliness & checking

 Low mood

 Anger outbursts

 Fear of losing father

 Suicidal Ideation

 Suspiciousness

 Talking and smiling to self

NATURE OF ILLNESS

Onset: Insidious

Course: Continuous

Progress: deteriorating
Precipitating factor: death of mother

Perpetuating factor: illness of father

Predisposing factor: no history of any psychiatric illness in family.

History of present illness:

Patient was apparently well till 2007, when her mother died suddenly in a road accident, patient

went into grief for many days. As she was the only girl child of her parents with two brothers this

made her family totally dependent on her for household purposes. So, she left her studies and

remained in home all the time, the circumstances at home affected her badly and she started to

feel lonely. The patient also reports that she began to miss her mother most of time and gradually

the patient’s interaction with other members of family decreased. Patient reported that she had

stopped living after the death of her mother. Her father reports that she would get easily irritated

whenever she was called and she would hold grudges against people and would fight with family

members on trivial issues. The father also reported that She would take much time in arranging

and cleaning things in kitchen e.g., cleaning and arranging the utensils again and again as she

was not getting satisfaction. Although these symptoms were present even before the demise of

her mother, there severity had increased. Apart from excessive concern for cleanliness and

arranging thing she had checking behavior. She used to repeatedly check gas and locks After

two years she began to have complaints of headache frequently, palpitations and also began to

feel restless and start bleeding from nose. Then her father took her to the SMHS hospital, there

she was examined by the doctors and they prescribed her medication but patient found no

significant improvement in her condition. After few months, her condition worsened again and

She was not able to sleep properly during night and her anger increased. Her mood used to
remain low and had suicidal thoughts. Then they sought the help of faith healer for almost two to

three years, which they eventually realized did not yield anything.

In 2012, the father of the patient fell ill and had a gallbladder surgery during the same period her

father was diagnosed with diabetes. The condition of her father developed in her fear of losing

her father. She then became enormously attached to her father and begin to coddle her father to

such an extent that she used to check her father’s breath at intervals during sleep just to confirm

is her father alright. As she reported that she has lost her mother and now she does not want to

lose her father.

While this fear was persistent , she became suspicious about other peoples intentions and would

say that people are jealous of her, as she has everything, and worlds most loving father.

Her father reported that during this time he noticed her indulging in self talking and self smiling

when alone and would not give any reasons for the same when asked.

She would also report that at times she hears voices of her mother and father calling her name.

In 2017, she started to remain alone and her interaction with friends and relatives decreased. She

also lost her interest in talking to her own family members especially brother and start showing

anger-outbursts. She would lock herself in room and would tell them to stay away from her, as

she feared that she will lose her temper. She would shout at her brother however would feel

guilty afterwards. Gradually the patient lost her appetite. She reported rapid changes in her mood

from irritability to extreme sadness. Day by day her irritability and aggression increased upon

which her father become worried so he bought her to hospital (SMHS) where a diagnostic

examination of patient was done and she was put on medication. However due to no diagnostic

clarification and no significant improvement she was referred for psychodiagnostic assessment.
Negative history:

No history suggestive of any :

 Significant Head Injury

 Epilepsy or fits

 Substance abuse

 Elation of mood

 Over-talkativeness

 Overspending

 Tall claims

Past psychiatric and medical history:

 There is no significant past psychiatric illness.

 There is a history of discectomy surgery for which patient was admitted for 4 months in hospital.

Family history:

Patient lives in a nuclear family of three members, compromising of her father and brother. They are three

siblings and patient is third in birth order. Her elder brother is married and lives separately with his wife

and two kids. Patient’s father is working in power development department. The patient used to spend

much of her time with her mother and used to discuss all her problems with her. In 2007 her mother died

suddenly in a road accident, as she was very closed to her mother and she could not bear this loss. After

her death she felt love deprived and she got attached to her father.

She grew up in a pleasant family environment. She was over pampered by her parents and all her

demands had to be quickly looked after to. She is close to her father and very attached to him. The patient
does not share cordial relationship with her brothers because she feels jealous when her father give

attention to her brothers. There is no significant history of any psychiatric illness in the family or up to

third degree relatives.

Personal and social history:

Perinatal history: the patient was born to full term c section delivery. She cried immediately after birth.
There is no history of any birth defect or prematurity or any difficulties during pregnancy, trauma or any
physical or psychiatric illness in mother.

Childhood history: the patient’s primary care takers were her parents. There is no history of any
developmental delay or childhood disorders. Patient witnessed healthy relationship between the parents.
The informant recalls she used to fight with other kids and show temper tantrums.

Educational history: the patient began her formal education at the age of 5 years. Informant and the
patient both could recall that she was average student academically and shared a cordial relationship with
her peers and teachers. She used to like going to school and never complained of anything about the
 school or her mates there. There is no history of truancy, absenteeism or learning difficulties in school.
She could not continue her studies after class 10 th as her mother died suddenly and she had to look after
all household chores.

Sexual and marital history: the patient reports to be in a relationship which lasted only for few months
but refuses having indulged in premarital sexual relationship. She was not comfortable in discussing her
masturbatory habits. There is no apparent history of gender incongruence.

Premorbid personality (PMP)

Attitude towards others: Patient was socially active person and she could make friends easily.

Use of leisure time: In his leisure time, the patient used to help her mother in household chores
and would spend time with her friends from neighborhood.

Predominant mood: having cheerful mood and used to enjoy every moment of life.

Attitude to self and others: patient reported to be over sensitive and used to get angry on trivial
matters.

Attitude towards responsibility: Patient reported to be responsible and used to be very

particular about all her responsibilities.

Religious beliefs and moral attitudes: Patient believed in Allah, and used to offer five times
namaz.

Fantasy Life: Day dreams about happy days.

Reaction pattern to stress: As per patient, she feels bad for not being able to continue her
studies like other batch mates. She always felt that life was unfair and does not give an equal
chance to everyone.

MENTAL STATUS EXAMINATION

1. General appearance and behavior
a) Appearance: Patient is a young female, but looked older than her stated age. She was well kempt and tidy,
was in complete touch with the surroundings, made and maintained eye contact, appropriately dressed up in
confirmative with the weather culture and situation.
b) Psychomotor activity: Patient sat very comfortably, leaning on a chair and cooperative enough to respond to
the questions I was posing.
c) Attitude towards the examiner: Rapport was also instantaneously very well established. She was cooperative,
attentive and willing to discuss her problems.

2. Speech
was initiated with normal reaction time and gave relevant and coherent answers. Volume and tone was
normal with increased productivity.

3. Mood and Affect

Mood: When the patient was asked how her mood was, she responded with ‘theek hai.’
Affect: appeared to be flat, didn’t appear to be congruent to the mood.
4. Thought
“Mai shadi nahi karna chahati hon mai nay is barai mai kabi nahi soncha hai mai pehalay
papa ki shadi karun gi thn dekhon gi”

“Mai nay apnay bhaiyon k lia apni padai sacrifice ki but inhunai mujay yh sila diya mai nay
as a mother role play kiya as a sister role play kiya kya mai yh deserve karti thi.”

“Mujay darr hai ki mai papa ko kahi ko na don mai nay apni maa ko khoya hai. Mujay
clearly yaad hai meri maa ki death kon say date aur time pay huwi”

(E) asked the patient what her views are about her illness
(P) “mai theek hon ,koi problem nahi hai mujay aur mai yahan bas papa k kehnay pay aayi hon.’’
There is continuity in her thoughts, normal process
5. Perception/Perceptual disturbances
Patient doesn’t report any form of perceptual disturbance.
6. Cognition

a) Consciousness and orientation

Patient is fully aware and conscious, no disturbance in level of consciousness. She was oriented to time, place and
person.
b) Attention & concentration
I asked the patient to repeat certain digits after me in both forward and backward format. In the forward part she
could repeat correctly up to five items and in the backward part she repeated well only up to three items correctly.
Patient was also asked to subtract number 7 from 100 but she could calculate only the first step at ease. She did put
her efforts to further steps but the calculations were wrong. So I asked to go for the easier one, i.e 50-3 in which she
appeared fairly well.
c) Memory
Immediate memory: I asked her to remember the names of three different things clock, table, computer and at the
same time I asked her about what she ate in dinner yesterday, s he responded with ‘chawal tha, aalu ki sabzi aur
dahi’ to which I got a nod from his attendant as well, and so recent memory was intact.
Remote memory: most of the history was given by the patient herself, remote memory was also intact. I then asked
her to recall the names of the things I previously had told to remember, and she could name all the three names
correctly. Immediate memory, intact
d) Intelligence and fund of knowledge: must be in the average range.
e) Abstract thinking: Intact (E) What does this mean, jesi karni wesi bharn i(P) aap jo karoge wesa hi milega.
(E) table aur kursi me ek jesa kya hai? (P) donu lakdi ke bane hai, baith sakte hai.

7. 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) ‘pass mai jo shopkeeper hoga mai yh uasy hi dongi.’
Social Judgement: Intact (E) asked what would you do if your brother fell ill ? (P) ‘me apni jaan laga dugi usey
acha ilaaj pohnchaogi.’

Personal Judgement: (E) asked what will you do when you go back home from hospital l(P) ‘meri koi aim hi nahi
hai.’

8. Insight: Grade II, slight awareness of being sick and needing help, but denying it at the same time.

Diagnostic Formulation

28 year old female, unmarried, belonging to average socio economic status, currently residing at lalbazaar was
brought to SMHS with complaints of decreased appetite, irritability, mood swings, loss of interest and anger
outbursts. She used to remain alone and her social interactions decreased. On MSE patient made and maintained eye
contact, appropriately dressed up in confirmative with the weather culture and situation. She was cooperative
enough and was giving relevant and coherent answers. Volume and tone was normal with increased rate. Affect was
flat and no abnormality could be elicited in thought and perception. Judgment was fair with grade II insight.

ASSESSMENT TOOLS ADMINISTERED AND RATIONALE FOR SELECTION OF TOOLS

FOR DIAGNOSTIC CLARRIFICATION

S.NO. Test Administered Rationale

1 Draw a Person Test(DAPT) To understand the role of personality in the

psychopathology of the patient

2 Rorschach Ink Blot Test(RIBT) To elicit psychopathology and clarify

diagnosis
 3 Millon Clinical Multi-Axial Inventory III (M To assess the personality traits of the patient
(MCMI-III)

4 Sack’s Sentence Completion Test (SSCT) To know the interpersonal relationships

5 International Personality Disorder To assess the major personality traits of the

Examination(IPDE) patient

6 Beck Depression Inventory (BDI) To assess the severity of the illness

7 Hamilton Anxiety Rating Scale (HAM-A) To assess the severity of anxiety level

8 Yale-Brown Obsessive Compulsive Scale (Y-

To assess the themes and severity of illness
BOCS)

DRAW-A-PERSON-TEST (DAPT)

On DAPT, the findings are suggestive of the patient showing a paranoid trend, problems in control of anger,
assaultiveness and aggression. Patient also displays dependency and regression. Findings are also suggestive of
patient having depressive features and she seems preoccupied in her past and is unable to emancipate herself
from her parents.

RORSCHACH INKBLOT TEST (RIBT)

Control and stress tolerance

On Rorschach protocol patient is suggestive of having limited available resources and becoming disorganized
under stress. The test findings indicate that patient function effectively in environments that are well structured
and reasonably free of ambiguity. The findings reflect that patient is investing considerable energy in a
massive containment and thus the vulnerability to stimulus overload and consequent disorganization is
considerable.

Situational stress

Findings are indicative that the patient is apparently under considerable situational related stress. The stress
tolerance of patient is lower than usual and her capacities for control are less sturdy than usual.

Affect

Findings are indicating the presence of an avoidant style. The findings further indicate a massive containment
or constriction of affect, the patient commits considerable energy to ensure that emotions are stringently
concealed and controlled. The findings also indicate an avoidant extratensive coping style, she is more prone to
use and be influenced by emotions than others.

Information processing

The test findings are suggestive of patient having avoidant style of personality. Findings also suggest an
obsessive like tendency towards perfectionism that causes the patient to become unnecessarily preoccupied
with the minutiae details. She feels uncomfortable about her decision making capabilities and find it easier to
deal with less complex, more easily managed stimulus fields. The patient is very guarded and mistrustful and
tries to minimize involvement with any perceived ambiguity. Findings further suggest the patient is very
cautious, overly conservative when defining objectives for achievement. Findings are also suggestive of patient
having adequate quality of processing but more conservative and economical than is typical.

Cognitive mediation

The test findings suggest that the meditational translations are generally appropriate in obvious situations but
tend to become less appropriate under other circumstances. This loss of meditational reality testing can be
caused by elements as- emotional or ideational interferences and problems in processing. Findings also suggest
that the patient is attempting to exaggerate or malinger symptoms. Further test indicates that some sort of
strange thinking in contributing to distortions of reality. The mental activities being generated by need and
stress experiences are interfering with effective mediation, probably by disrupting attention and concentration
and intruding into logical patterns of thought. Findings further indicate that less conventional, more
individualistic responses will occur, even in situations that are simple and precisely defined.

Ideation

The findings suggest that the patient is avoidant extratensive that is she is very inclined to use and be
influenced by feelings and also depends on external feedback.

Self perception

The test findings suggest that the patent is having less self awareness than is usually the case and tend to be
more naïve about her that might be desirable. Findings also indicate that person is less mature and frequently
have very distorted notion of her. This limited self awareness sometimes serves very negatively in decision
making and problem solving activity and creates a potential for difficulties in related ton others. Findings
further reveal that patient is having negative impression about her and is very emotional.

Interpersonal perception and behavior

Findings also indicate that patient tends to express her needs for closeness in ways that are dissimilar to those
of most people that is she is more conservative than might be anticipated in close interpersonal situations
especially those involving tactile exchange. Test findings also indicate that the patient is more defensive in
interpersonal situations than are most people and often relies on displays of information as a way of
maintaining security in those situations.

Summary

 Low stress tolerance

  Avoidant-extratensive coping style
 An obsessive like tendency towards perfectionism.
 Meditational translations are generally appropriate.
 Less self awareness and negative impression about herself
 Conservation in close interpersonal situations

MILLON CLINICAL MULTI-AXIAL INVENTORY III (MCMI-III)

Clinical personality patterns

The clinical personality pattern syndrome indicated in patient are - borderline (80) and negativistic personality
pattern (104).She appears overly preoccupied with securing affection, she has instability and lability of mood
and have difficulty maintain a clear sense of identity. She appears to be indifferent to criticism of others. She
has a tendency to show erratic pattern of explosive anger or stubbornness intermingled with periods of guilt
and shame.

Clinical syndrome

The clinical syndrome pattern indicted in patient are –anxiety (93) and dysthymia (98).High score on anxiety
reflects presence of pathological symptoms which may manifest as feeling apprehensive, tense, indecisive and
restless. She may seem worrisome. There is also an inclination towards patient having feeling of sadness,
discouragement, guilt, low self esteem and pessimistic attitude towards the future.

Severe clinical syndrome

The severe clinical syndrome pattern indicated in patient is depression (105). Elevation on major depression
scale shows presence of depressive features like sad mood, hopelessness, ideas of worthlessness and somatic
symptoms. The test findings are also suggestive that patient is incapable of functioning in normal environment.

SACK’S SENTENCE COMPLETION TEST (SSCT)

The test findings on SSCT are suggestive of patient having mild disturbance in the domain of attitude towards
father, attitude towards her own abilities and patient is having mild guilt feelings. The findings are further
suggestive of patient having severe disturbances in the domain of attitude towards friends and acquaintances
and she tends to have fear.

BECK DEPRESSION INVENTORY (BDI)

On BDI, the patient scored 41, which is suggestive of patient having severe depression.
HAMILTON ANXIETY RATING SCALE (HAM-A)

On HAM-A, the patient scored 24, which is suggestive of patient having moderate anxiety.

YALE-BROWN OBSESSIVE COMPULSIVE SCALE (Y-BOCS)

On Y-BOCS patient scored 12 on obsessions and 11 on compulsions with total scaled score of 23 which is
suggestive of patient having moderate level of OCD.

Provisional Diagnosis:

• Other Reactions to Severe Stress (Chronic Complicated Grief) with OCD

with Moderate to Severe Depression with Psychotic features

Points in favor of diagnosis:

From history, MSE and Assessment:

• Subjective distress and emotional disturbance interfering with social functioning.

• Dramatic behaviour and outburst of violence.

• Depressed mood, anxiety, worry, inability to cope, plan ahead.

• Excessive concern for cleanliness & checking.

• Self-talking and self-smiling

Differential Diagnosis:

• OCD with severe depressive episode with psychotic features with mixed
personality traits (schizoid and passive aggressive traits).

Points for diagnosis:

From history, MSE and Assessment:

• Excessive concern for cleanliness & checking

• Low mood, decreased appetite, decreased sleep and suicidal ideation

• Self-talking and self-smiling

• Few activities provide pleasure

• No interest in sexual experiences

• Lack of close friends or confiding relationships

• Erratic pattern of explosive anger or stubbornness intermingled with periods of guilt and shame