CASE HISTORY – 02

(05 SEPTEMBER 2022)

Name : Mr. H M

Age : 21 years

Gender : Male

Marital Status : Unmarried

Education : Pursuing Graduation

Family Type : Nuclear Family

Occupation : Student

Religion : Hinduism

Socioeconomic status : MSES

Locality : Urban

Informant : Father and Sister

Psychiatrist : Dr. Arjun Arya

Psychologist : Dr. Amit Dwivedi

Reliability & Validity : The information given was reliable and adequate
for the assessment
History of Present Illness:

Chief Complaints

Mr. H M, 21 years old unmarried male belonging to MSES urban area of Kurukshetra living in a
nuclear family was referred for comprehensive psychological evaluation with the chief complaints of
alteration of thoughts, obsessive thoughts, restlessness, difficulty in concentration due to which he felt
that his artistic qualities are diminishing.
In a detailed interview, the client mentioned that he started observing changes in his thought patterns
which caused a disturbance in his daily day-to-day activities like- going to college, meeting people,
studying, and staying at the hostel. He also mentioned he opted for B. Tech (Civil Engineering), and
during his 2nd Year in the course, he had to study ‘structures’ which he wasn’t aware of and his interest
in subjects gradually started to decline. The client also mentioned that he does not want to pursue the
course further as the university’s teaching standards are not satisfactory.
He stated that about 4-5 months ago while he was staying at the hostel, he started to show concern
about bacteria/ germs around him, the client also mentioned an incident where he was concerned about
‘Red and Green coloured walls that were present in his hostel rooms. He said if he stayed in Red colour
room something bad would happen and the Green colour room was safe to stay. He also said that when
he shook hands with someone, he had this urge to wash his hands though he had control over this
thought and did not act on the thought immediately. There have been incidents where he has repeated
patterns (exiting through a specific door, if not passing through that particular door he would go back
and again pass through that door). The client also stated that he started to over-analyze everything in his
surroundings, he believed that everything around him is going to cause him damage and he said his
thoughts are paradoxical in nature.
He also left the hostel and went back home (around 2 months ago) and was not willing to go back to the
hostel and continue studying the same course. He also stated that he does not want to continue taking
treatment from the Psychiatrist he has been seeing before and also denied taking medications for the
treatment around 1 ½ month ago.
Due to these concerns, he has been socially less active in his environment and it has started to impact
his daily activities and other academical areas as well (poor attendance, does not want to go back to the
hostel, no longer interested in the course he has been pursuing).

Onset : Insidious
Course : Continuous
Duration : 4-5 months

Informant History:

Informant: Father and Sister

The informant stated that the client was obedient and competitive since he was a young boy. He is
intelligent and used to consistently fetch good grades. The client had interest in playing cricket and has
played for the school, but the client’s father believed he is a bright student therefore he should be
focusing more on his academics rather than on sports. The client changed school in class 10 th and the
informant saw a significant change in his behaviour, he neglected his daily activities, didn’t wake up
for school and didn’t take much of interest in the studies. After his matriculation he planned to move to
Chandigarh for JEE Coaching along with his friend, though his friend didn’t come with him for
coaching, the client felt little disturbed and had trouble adjusting to the new environment. His interest
for studies kept declining, started remaining distant with less social interaction and increased in
sleeping pattern, and absenteeism from classes. The client spent long hours in washroom bathing and
brushing teeth. Informant also stated that he during his senior secondary class he never studied or made
notes throughout the session, he studied night before the examination and was still able to secure good
marks. After the completion of his schooling, the client took a gap year to explore his academic
options, during that time period the client’s phone usage significantly increased, the informant
mentioned that he used to watch web series/ movies all day and he started to associate with characters
of the things he watched, his sleeping pattern also changed, he became fond of cinema at this time.
In 2021, the client took admission in B.Tech (Civil Engineering) Course in Patiala. He did not like the
environment of the university, and stated that the faculty and fellow students are nothing compared to
his level of intellect, and he deserves much better than this. The client stayed at hostel, missing his
classes on regular basis due to which he had a backlog in his first semester and he assured his father
that he would perform better in the next semester. The informant also mentioned that during the first
year when client came back home his inclination towards spirituality increased, he read spiritual books,
kept long hair and nails; when he was asked to cut them short the client said that he read in books that
long hair contains energies, so he won’t cut them short, he remained rigid about his belief for a long
time. The informant (Sister) also mentioned that he became anxious about the sexual activities and
believed that all these things are sinful and should not be practiced and even thought about. In May
2022, the client called his parents and asked them to take him back home from the hostel, upon
returning home family members started to notice that he spends a lot of time in bathroom for washing
and bathing. The client started to take treatment from Kurukshetra, Haryana for Obsessive thoughts and
compulsive acts. After taking medicine he used to remain well for 3-4 days, after sometime he started
to complain about the medicines that they have adverse effect on the brain and it will damage his brain
cells and hamper his skills. The client remains irritable, rigid, aggressive and concerned about the
medications most of the time.

Negative History:

● No significant history of any brain/head injury

● No significant history of self-harm.
● No significant history of euphoric/ elated mood
● No significant history of seizure/ epilepsy
History of Past Illness:

Past Psychiatric History : The client was diagnosed with Obsessive-Compulsive-Disorder

four-five months ago; he has been taking medicine for the same for the prescribed course but currently
is in denial for taking medication.

Past Medical History : Not Significant

Family History:

Client is the youngest among two siblings, one elder sister. He shares a close bond with his sister.
Father is a retired professor and mother is a lecturer and sister is pursuing MBBS; his parents share a
cordial relationship among themselves. Mother was treated for depression and was put on medications
after the death of maternal grandparent in 2007. There was also a case of suicide in the third degree
relative due to brain disease.

Personal History:

Birth and Developmental History : FTND, All milestones achieved.

The client was bright and smart since his childhood. He was competitive and took part in all
extracurricular activities and he possessed good level of intellect as to his other children around him.

Educational Qualification:

The client mentioned that he has completed his matriculation from Kurukshetra, Haryana and senior
secondary education from Kurukshetra as well through correspondence. During this course he also has
taken coaching for JEE from Chandigarh. Currently he’s been pursuing his Graduation from Patiala,
Punjab.

Sexual History: He got first knowledge of sex at early age (6-7 years old) from other senior class
students. He hasn’t had sexual intercourse. There has been significant decline in sexual interest and
masturbation practices.
 Mental Status Examination

● Language of the interview : Hindi and English

● Time taken : 35 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, Anxious
● Motor activities & behaviour : Goal Directed; Purposive
Movements

● Speech : Relevant & Coherent

 Volume : Soft
Pitch : Low
Tone : Decreased
Tempo : Normal

● Attention & Concentration : Aroused & Sustained

● Orientation : Orientation 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 : Worried, Anxious, Tensed.
Possessions : Obsession, Compulsion

● Mood

o Range : Decreased
o Reactivity : Minimal
o Communicability : Present
o Mobility : Present

● Affect : Blunt Affect

● Hallucinations : Absent
● Trance & Possession : Absent
 ● Judgment

o Personal : Slight Impairment

o Social : Intact
o Test : Impaired

● Insight : Grade IV

PSYCHOLOGICAL TESTS

Sr. No. Tests conducted Score & Interpretation

 1. Beck Depression Inventory 11: Mild mood disturbance

PGI- Health Questionnaire

2. A: 18.75% : (Mild Physiological Distress)

B: 22.72% : (Mild Psychological Distress)

Overall: 21.5% : (Mild Physiological &

Psychological Distress)

3 Yale Brown Obsessive Compulsive Obsessions: 7

Scale Compulsions: 5
Total: 12

SUMMARY

Mr. H M, 21-years-old, male belonging to a MSES of Kurukshetra, Haryana, living in a nuclear family
presented for psychological evaluation with the chief complaints of increased sleep, irritability, low
energy, difficulty in concentration, obsessive thoughts and checking compulsion, indecisiveness,
aggressive behaviour. According to his MSE, the client was appropriately dressed and rapport was
established with ease, consciousness alert, affect was blunt, eye contact was minimal, mood range
decreased, tempo and pitch were slow, memory was intact, with an average intelligence, test judgment
impaired, manner of relating was tensed.
On Psychological evaluation, PGI-HQ indicated mild physiological and psychological distress, Beck’s
Depression Inventory indicated mild mood disturbance, Y-BOCS indicating several obsessions and
compulsive acts. The insight level Grade IV was present; the client has awareness of illness and wants
to take the treatment for the same. The protocol goes consistent with the clinical impression of
Obsessive-Compulsive Disorder.

Recommendation: The is being advised psychoeducation, pharmacotherapy and intensive counselling

sessions.

Follow-up: The client has been taking counselling sessions, the sessions focus on changing difficult
thoughts, behaviors, and emotions.

Dr. Amit Kr. Dwivedi

Psychologist