Socio-demographic details: Mrs.

MP, a 47 years old Hindu female living in an sub

urban locality as a part of a lower SES nuclear family educated up to 6 standard and a
th

housewife..
Informant: Daughter and husband; Information: Inadequate and reliable

History of Presenting Illness:

The patient was apparently maintaining well until 2008 when there was a reported theft in the
household and all the valuables were stole. Her husband on being informed about the theft beat
her up and the episodes of domestic violence in the household increased, as reported by the
youngest daughter (informant). The patient developed a doubt on her neighbor (sister-in-law)
regarding the theft. Slowly as reported by the daughter, doubt on other neighbours also
developed and the patient refrained from going out and interacting with the social group. The
daughter also reported that around the same period, the patient would remain aloof and was
observed to be disinterested in most things that she once enjoyed. 
According to the informant, the patient who would generally remain calm and not react when she
was being beaten up by the husband or scolded, would now have an anger outburst and start
screaming and fighting back whenever told to do anything. Her sleep and appetite as reported by
the informants were maintained and would increase on certain days but was not hampered. She
would be able to perform her duties in the home but was found to be self-muttering most of the
times.

When the condition of the patient started deteriorating and the odd thinking caused the family
suspicion, the husband and her mother took her to several faith healers but no improvement was
seen. This continued for about a year and during the same period her symptoms exacerbated. 

She would be found self muttering according to the informant and on being told to stop, she
would scream and say that the man who she thinks has his soul within her, is threatening to kill
her and her family. She said that the reason he wishes to kill her is that that due to the special
powers she is able to see his two dead wives and they don’t want their identity to be found out
and she will disclose their true identity.

In 2012 after the insistence of the daughter, the husband took the patient to RML hospital and
medication was begun. The patient reported that she would feel extremely drowsy due to the
medication and hence requested that it would be changed. The daughter reported that the
medicines were effective and the symptoms reduced. After the patient was settled to a
manageable extent, she was brought back home but the medication continued and would visit
once in 1-3 months depending on the requirement. 
The informant reported that the symptoms had subsided but the doubt on the man remained and
would at times hear the voice of the man as well. 

1. Provisional Diagnosis
2. Differential Diagnosis
3. MSE
Provisional Diagnosis- F20.6 Simple Schizophrenia

Points in Favor:-

 The subject had said how there was a man inside her soul, who threatens to kill her
and her family, because she has a special power to see dead people.
 This statement alone provides enough evidence for persistent delusions of other
kinds that are culturally inappropriate and completely impossible, such as religious or
political identity, or superhuman powers or abilities. This makes the diagnosis of
schizophrenia to be concrete.
 Her symptoms fit well with the common symptoms of Simple Schizophrenia, like
apathy, avolition, anhedonia, reduced affect display, lack of initiative, lack of
motivation, and low activity.
 These are significant evidence for a consistent change in overall quality of some
aspects of life- personal behavior, loss of interest, aimlessness, a self-absorbed attitude.
 Mrs. MP, had developed a doubt on her neighbor, and even started doubting her
neighbors, so much that she refrained from going out and interacting with social
group, showing Social- withdrawal.
 Her being disinterested in most things and remaining aloof show a loss of interest.
 She was seen to be self-muttering quite a lot, which shows self- absorbed behavior.

Differential Diagnosis:-

 She is seen to have doubts on her neighbors, which shows paranoid nature.
 The very point that she thinks there is a man inside her soul, provide significant
evidence for hallucinatory voices in the head that threaten patient or give commands.
However, this is a key point for Paranoid Schizophrenia, rather than Simple
Schizophrenia.
 Mrs. MP also withdrew from interacting with others, showing social withdrawal that
is one of the symptoms, for both simple and paranoid schizophrenia.

Due to lack of information, a clear diagnosis of the case as F20.0 Paranoid Schizophrenia
is unlikely to occur.

However, if the extended case study have symptoms that are much irrelevant and cause
clashing symptoms with the provisional diagnosis, then the diagnosis of F20.3
Undifferentiated Schizophrenia can be given (This is because Undifferentiated consists
of those cases where due to lack of or too many symptoms, diagnosis under any one sub-
type is seen to be impossible).
 1. MSE -

General Appearance and Behavior

Gait : - normal

Posture: - stiff

Grooming, hygiene and dressing: - impaired

Looking age appropriate: - Normal

Level of Consciousness: - Alert

Facial Expression: - tense, frightened

Aspects To Note In Behavior

Rapport: - established

Eye-to-eye contact: - would not be established

Came by self/ bought by others: - by others

Attitude towards Examiner: - hostile, distracted, suspicious

Aspects To Note In Motor Behavior

Any abnormal motor movement: - mannerisms, hyperactivity tics

Psychomotor activity: - decreased.

Speech

Quantity: - paucity

Coherence: - coherent

Relevance: - relevant

Pitch:- Normal

Tone: - Vary, monotone

Volume: - Vary, monotone

Rate: - Pressured
 Reaction Time: - Relevant with surrounding

Fluency: - hesitant

Mood

Subjective: - Suspicious of other person, irritated.

Objective: - irritable, apprehensive

Affect- Congruent with context , Restricted, blunted emotions, reacts appropriately to

change in context.

Thought

Thought process: - tangeniatility, word salad.

Content: - Anxiety, aggressive tendency, personality disorders, major depressive

episode (MDE).

Possession of Thought:- none elicited

Perception

Sensory Distortion: - none elicited

Sensory Deception: - auditory hallucination

Cognitive Functions

Orientation: - average

Attention and Concentration: - average

Memory: - average

Intelligence and General Fund of Knowledge: - average

Abstract Thinking: - average

Judgment: - Impaired

Insight: - Level 6.