Socio-demographic details: Mr.

X, 24 years old, unmarried Hindu male, currently

living in a nuclear family, completed his B.Com in Honors and belonging to upper
middle socio economic status.
Informants: Mother and self
Information: Reliable and adequate

Chief presenting complaints

 Continuous feeling of sadness
 Feels less confident
 Feeling of restlessness and uneasiness
 Decreased sleep 
 Increased fatigability 
 Continuous repeated, uncontrollable thought related to past unwanted
event associated with feeling of guilt              
 Ideas of harming self or ending life 

Onset: gradual            Course: continuous        Progress: deteriorating

History of presenting illness:
Sudden and unforeseen end in long term relationship which led to his low mood
and continuous feelings of sadness, which were aggravated by his futile attempts to
win her over. Eventually these symptoms persisted into developing low self-
esteem, which was triggered by the news of his girlfriend getting into a new
relationship, 2 months after their break up. 
These distressing feelings exhibited by the client gradually manifested into
restlessness which in turn progressed into disturbed sleep, wherein he complained
of having trouble falling asleep and would spend the night tossing and turning.
Having been consumed by these thoughts, client reported of feelings of
fatiguability, which was exacerbated by the disturbed sleep. Eventually he reported
of having difficulty concentrating on preparing for his entrance exam, because of
the negative thoughts. 
After having managed his day to day activities, despite having been distressed by
the life events, he came across an article 3 weeks back, on minors getting recruited
as sex workers which led to him to think back to his past where he had a similar
encounter. He recalled that the girl he was with was slightly short in height and he
therefore assumed that she was a minor. This triggered his feelings of guilt and
self-disgust, wherein he kept saying to himself that how he could have done
something this bad and that he is a child rapist
As the negative thoughts persisted, he tried to make himself feel better by telling
himself that he wasn’t even interested in the girl that provided the services that
day. He also tried to convince himself that, she did give him her consent to engage
in the act, so technically, he hadn’t done anything wrong.
Eventually, all these thoughts culminated into him developing thoughts of ending
his life, wherein he stated that he wouldn’t be able to live with the guilt of having
the ‘rapist’ tag for the rest of his life. However, he never acted on these thoughts,
which suggests that they were passive.
These symptoms reportedly caused disturbance in day to day life functioning i.e.
poor sleep quality, fatigability and social withdrawal

Past psychiatric history: None reported

 Provisional diagnosis
 What further information can you elicit?
 MSE
 Psychometric assessment 

Provisional Diagnosis

F32.2 Severe Depressive episode

Points in Favor:-

 The Onset of the disorder was for at least 2 weeks. Also, this was the first (single)
depressive episode, Mr. X had experienced, as can be inferred from the past
psychiatric history.
 The patient’s history provides evidence for all 3 core symptoms of depressive
episode:
- Low mood,
 - loss of interest in performing life events
- fatigability which shows loss of energy.

 The history of illness also provides evidence for several cognitive symptoms, like
- reduction in concentration,
- reduction in self esteem and self-confidence,
- had ideas of guilt and self-disgust
- ideas of harming self or ending life
- decreased sleep
 For a definite diagnosis of Severe Depressive Episode, all 3 core symptoms and at
least 5 cognitive symptoms, of depressive episode must be present. This criteria, was
fulfilled as stated above.

Mr. X’s illness was found to have a gradual onset, with continuous course and a
deteriorating progression. All of these, along with his social withdrawal, and increased
thoughts of self-harm, show possible psychotics may arise. After the onset of psychotics,
the patient may even hear people telling him to kill himself, to get rid of the guilt, making
the ideas of suicide to turn into active. Also, as the onset of the illness is gradually
increasingly, the diagnosis may also change to depression or major depression disorder in
the future.

MSE -

General Appearance and Behavior

General Appearance: - Mr. X appeared to be properly dressed

Attitude towards Examiner: - The subject appeared guarded, but tired too.

Level of Consciousness: - lethargic

Gait and Posture: - the posture denoted a stooped posture.

Motor activity: - the patient keeps stammering over words, fidgeting, and shows few
spontaneous movements.

Psychomotor-activity: - Decreased

Eye-to-eye contact: - downcast gaze; minimal eye contact.

Rapport: - rapport was established with a little difficulty.

Speech

Rate and Quantity: - there was paucity of speech and pressured speech. The answers
also exhibited delayed responses to questions.

Volume and Tone: - Volume is decreased and tone varies between soft and
monotone

Flow and Rhythm: - slow and stammering

Reaction Time: - slow

Relevance: - The patient answered questions relevantly, but the questions have to
be repeated, because of the patient’s decreased ability to function(due to tiredness).

Mood

Subjective: - Questions asked like “ How are you feeling these days? What about the
girl, you slept with years ago? How do you feel, when you think back about her?”

He recalled that the girl he was with was slightly short in height and he therefore
assumed that she was a minor. This triggered his feelings of guilt and self-disgust,
wherein he kept saying to himself that how he could have done something this bad
and that he is a child rapist

Objective: - guilt and self-disgust

Quality of Effect:-

i. Appropriateness: - Congruent with the context

ii. Range: - Constricted
iii. Intensity: - Blunted emotions
iv. Responsiveness: - Reacts appropriately to changes in context

Form of thought: - tangentiality, perseverations

Content: -

Questions asked: - “You said you wanted to kill yourself, but never acted on these
thoughts. So, to reduce the guilt, did you do anything specific?”

“You are withdrawing yourself from people, but why? Do you think they will say
something to you?”

Substance Abuse, and Social Anxiety.

 He stated that he wouldn’t be able to live with the guilt of having the ‘rapist’
tag for the rest of his life. However, he never acted on these thoughts, which
suggests that they were passive.

Perception: - Hyperacusis

Cognition

Orientation: - orientated to time, place and person

Attention and Concentration: - Concentration is especially below average

Memory Immediate: - intact

Recent: - intact

Remote: - intact

Intelligence and General Fund of Knowledge: - average level of intelligence

Abstract Thinking: - Concrete Thinking

Judgment Test judgment: - intact

Social judgment: - impaired

Personal Judgment: - intact

Insight: - Level 1

Psychometric assessment: -

 Beck Depression Inventory (BDI)

 Hamilton Rating Scale for Depression(HDRS)
 Beck Hopelessness Scale.