CASE HISTORY – 09

(16 OCTOBER 2022)

Name : Miss A R N

Age : 16 years

Gender : Female

Education : Senior Secondary School

Family Type : Nuclear Family

Religion : Hinduism

Socioeconomic status : MSES

Locality : Semi-Urban

Psychiatrist : Dr. Arjun Arya

Psychologist : Dr. Amit Kr. Dwivedi

Reliability & Validity : The information given was reliable & adequate for
the assessment

History of Present Illness:

Chief Complaints

Miss A, 16-year-old female belonging to MSES semi urban area of Rohru, Himachal Pradesh, living in
a nuclear family was presented for comprehensive psychological evaluation with the chief complaints
of academical stress, overthinking, mood fluctuation, annoyance, irritability, weight loss, social
withdrawal and decreased interest in activities that once excited her.

On detailed interview, the client mentioned that she started to observe these signs when she moved to
her hostel in Shimla about four months ago, she has started to experience anger even on the slightest
stressor but was not able to ventilate that emotion. She started to remain anxious about her academics
that the syllabus is vast and she has to dedicate great amount of time to her studies. The client felt hard
to adjust in the new environment of the hostel. She started to withdraw herself from social interaction
as she felt it was overwhelming and waste of time. When client went back home, she also decreased her
interaction with parents. She felt concerned about her changing behaviour but couldn’t express her
emotions clearly. The client also mentioned that she has habit of biting on cuticles and even if she tried
to stop herself from doing so, she couldn’t stop acting upon these urges. It also makes her angry when
her belongings are slightly out of proportion (when her books are not kept in her desired order).
Sometimes she was able to control her urge to keep things in order but back in mind she kept thinking
about the disorganised belongings. The client also mentioned an incident where she felt her name was
being called out by some female voice in a medium pitched tone.

Ever since she was a child she showed immense interest in History subject, but as she grew up, she
realised that she isn’t much interested in History (“life ko illusion mein rakha tha”) and wants to
explore more subjects. The client also mentioned that she had this obsession of running towards the
switch board, touching it and coming back in her childhood. The client stated that she prefers staying
isolated and does not want to share or express her thoughts with others.

Onset : Insidious
Course : Progressive
Duration : Five months

Informant History:

Relation- Father & Mother

The informant mentioned that the client moved to hostel at Shimla to pursue her senior secondary
classes about 4-5 months ago. At times the client experienced feeling of isolation from her social circle
and remained aloof from parental interaction as well. She also experiences a brief period of sadness and
anxiousness, and most of her anxious behaviour was due to her academics. The client also mentioned
that due to academical stress she gets easily annoyed and irritated. Ever since she was a child, she had a
large group of friends and was excellent in her studies. As she grew up, the client developed interest in
reading novels. The informant also mentioned that, she also has written novels of her own named
‘Dracula’, her genre of writing revolved around fictional characters, and sci-fi amused her. Over a
period of time, she started to lose interest in socializing with peers and other worldly matters- she often
said that experiencing and buying new things is just waste of money (sab moh maya hai). It was
observed by the informants that client has been distant from them as well, she would not initiate the
conversation.
informants mentioned that the client fears to lose her academic position, as she cannot accept the
failure.
To channelize these emotions the client has also joined sports activity ‘Grippling’. The client also
showed interest for Psychology subject and asked the informants to let her pursue the said subject.
During the lockdown her duration of isolation increased and she spent most of her time alone and
reading books. The informant also stated that, client also suffered from low levels of vitamin D.
Informants also said that while she stayed at her hostel, client sounded better while they had a
telephonic conversation with her.

Negative History:

● No significant history of any brain/head injury

● No significant of self- harm/ suicide attempt
● No significant history of euphoric/ elated mood
● No significant history of seizure/ epilepsy

History of Past Illness:

Past Psychiatric History : Not Significant

Past Medical History : Not Significant

Family History:

the client is the only child of her parents. She lives in nuclear family and her parents share a cordial
relationship among themselves. After the birth of client her mother developed various ailments like
hypertension, hyperthyroid, low levels of hemoglobin. Client’s mother also underwent surgery for her
knees. Client’s grandmother had a history of brain tumor and she passed away due to tumor.

Personal History:

Birth and Developmental History : FTND, all milestones achieved appropriately.

Behaviour During Childhood :
The client had a shy nature during her infancy period, later she developed a sense of confidence as she
grew up and had a large group of friends. She possessed a good level of intellect and secured good
grades in her academics.

Educational History: The client studies in a school near to her house from Nursery to class 4th. Later
they switched school and studied there till class 10th. The client was well adjusted in the school
environment, was liked by her teachers and had a good academic performance throughout her
secondary classes. She moved to hostel in Shimla for her further studies. The client is currently
pursuing her senior secondary with Humanities as her stream and with subjects, History, Geography,
English, Hindi.

Menstrual History: Menses started at the age of 13 year; has regular periods and flow usually remains
normal but has been experiencing a slight change in flow from past three to four months; does not have
any pre-menstrual symptoms; there are no fluctuation in mood before and during the periods.

Mental Status Examination

● Language of the interview : Hindi and English

● Time taken : 30 minutes
● Level of consciousness : Alert
● General appearance and behaviour : Appropriate
● Handedness : Right-Handed
● Rapport : Established
● Eye contact : Minimal
● Facial expressions : Minimal
● Attitude towards the examiner : Cooperative
● Manner of relating : Tensed
● Motor activities & behaviour : Goal Directed; Purposive
Movements
● Speech : Relevant & Coherent
Volume : Low
Pitch : Low
Tone : Decreased
 Tempo : Normal
● Attention & Concentration : Aroused & Sustained
● Orientation : Oriented towards time, place, person
● Memory
Immediate : Intact
Recent : Intact
Remote : Intact
● Abstract ability : Semi-Rational
● General information : Average
● Thought
Stream : Spontaneous
Form : No FTD Present
Content : Worrying, preoccupation with some
academical concerns
Possession : Obsessions & Compulsions
● Mood
Range : Decreased
Reactivity : Present
Communicability : Present
Mobility : Minimal
● Affect : Blunt Affect
● Hallucinations : Present
● Trance & Possession : Not Present
● Judgment
Personal : Slight impairment
Social : Intact
Test : Impaired
● Insight : Grade II
 PSYCHOLOGICAL TESTS

Sr. No. Tests conducted Score & Interpretation

1. Beck Depression Inventory 30 : Severe Depression

2. PGI- Health Questionnaire A: 31.25% : (Mild Physiological Distress)

B: 54.% : (Moderate Psychological Distress)

Overall: 44.10% : (Moderate Physiological &

Psychological Distress)

3. GRID HAM-D 17 23: Severe Depression

4. Adult Anxiety Checklist 20: Moderate Anxiety

5. Yale Brown Obsessive Compulsive Scale Obsessions: 7

Compulsions: 5

Total: 12

6. Brief Psychological Rating Scale BPRS: 57

SUMARRY

Miss A, 16 year old, female belonging to a MSES of Rohru, Himachal Pradesh, living in a nuclear
family, was presented for psychological evaluation with the chief complaints of distress, emotional
instability, hostility, suspiciousness, auditory hallucination, guilt-feelings, anxiousness, irritability,
depression, obsessive thoughts and compulsive actions with progressive course for past five months.
According to her MSE, the client was appropriately dressed and rapport was established, consciousness
alert, affect was tensed and anxious, eye contact was maintained, mood range was normal, tempo and
pitch was normal, memory was intact, average intelligence, test judgement slightly impaired.
On psychological evaluation, PGI HQ indicated moderate physiological and psychological distress,
BDI indicated Severe Depression, GRID HAM-D indicates Severe Depression, Adult Anxiety
Checklist indicates Moderate level of anxiety, YBOCS indicating obsessions and compulsive acts. The
insight Grade II was present, the patient has awareness of illness but was in denial of treatment. The
protocol goes consistent with the clinical impression of Depression, Obsessive-Compulsive Disorder
with Psychotic Symptoms.

Recommendation: The client has been recommended intensive counselling session along with
pharmacotherapy.

Follow-up: The client has not showed-up for the follow-up on the said date.

Dr. Amit Kr. Dwivedi

Psychologist