CASE HISTORY – 07

(10 OCTOBER 2022)

Name : Mrs. P N

Age : 55 years

Gender : Female

Marital Status : Married

Education : Senior Secondary Education

Family Type : Joint Family

Religion : Hinduism

Socioeconomic status : MSES

Locality : 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

Mrs. P N, a 55-year-old female belonging to MSES of the urban area of Haryana and living in a joint
family, was presented for a comprehensive psychological evaluation with the chief complaints of a sad
mood, irritability, anxiety, forgetfulness, loss of interest in activities that she once enjoyed, social
withdrawal, feelings of self-doubt and guiltiness, stress, increased sleep, and loss of appetite.
On a detailed interview, the client mentioned that she wanted to stay in isolation, which increased her
stress levels, and made her stay in bed all day long and didn’t want to go out of her house. The client
also mentioned she feared enclosed spaces, and she tends to forget her day-to-day activities. Earlier, she
used to engage in the social environment, but currently, she feels the urge to stay indoors. The client
mentioned she had been taking treatment and medications for depression for the past four to five years
as she got easily stressed about her household chores and had a hard time letting go of things. The
client also stated that previously she suffered from severe headaches, due to which her sleeping cycle
got disturbed, and only taking medications made her fall asleep better. She spent most of the day doing
domestic activities and lying in bed. She also mentioned that her interest in being with her
grandchildren decreased, as she felt annoyed in their presence and got easily irritated when they made
noise while they played at home. The client tends to have a lot of gastric issues lately, along with a dry
mouth.

Onset : Insidious
Course : Progressive
Duration : 2-3 Years

Informant History:

Relation- Husband

The informant gave consistent information as per the client, furthermore, he mentioned that for the past
4-5 years, she had been having a brief period of the above-mentioned symptoms, especially with the
changing of the seasons. The informant also stated that she got suspicious of people living around her
and would often say that they would harm them or blame them for something. Due to these incidences,
she spent most of her time in a room isolating herself, she refused to go outside and talk her feelings
out. Often her posture remained drooped, and she quietly sat in one place for a long period of time. The
informant also mentioned that she remembered all the things but felt hesitant to speak up, and held back
her thoughts.

Negative History:

 Increased Sleep
 Decrease Appetite
 No significant history of any brain/head injury
 No significant of self- harm/ suicide attempt
  No significant history of seizure/ epilepsy
History of Past Illness:

Past Psychiatric History : Started seeking treatment for depression 4 years ago from
Haryana and has been continuing the same till date. The client remained asymptomatic for one and a
half year, recently she has been again experiencing the symptoms of depression.

Past Medical History : The client has been taking medications for thyroid and she
also suffers from knee ailment.

Family History:

The client shares a cordial relationship with her family, she lives in a joint family with her husband,
two sons and a daughter-in-law along with two grandchildren. History of psychiatric disorder in first
degree of relative.

Personal History:

Birth and Developmental History : Could not be elicited as no biological parent was
available at the time of the interview.

Educational History:

The client completed her schooling from her hometown up-to secondary education level.

Menstrual History:

Menarche started at the age of 13years, the flow was regular, the period cycle was regular. Around 7
years ago client had menopause.

Marital History:

The client had an arrange marriage, and shares a cordial relationship with her partner.

Pre-morbid Personality:

The client had been a confident and carefree person. She enjoyed socializing with people, had greater
sense of self and she was satisfied with her life. She was a religious person. The client enjoyed hobbies
like stitching and knitting.
 Mental Status Examination

● Language of the interview : Hindi

● Time taken : 20 minutes
● Level of consciousness : Alert
● General appearance and behaviour : Appropriate
● Handedness : Right-Handed
● Rapport : Established
● Eye contact : Maintained on and off
● Facial expressions : Minimal
● Attitude towards the examiner : Cooperative
● Manner of relating : Guarded
● Motor activities & behaviour : Goal Directed; Purposive
Movements
● Speech : Relevant & Coherent
Volume : Low
Pitch : Low
Tone : Decreased
Tempo : Normal
● Attention & Concentration : Aroused & Sustained
● Orientation : Oriented
● Memory
Immediate : Intact
Recent : Slight Impairment
Remote : Slight Impairment
● Abstract ability : Concrete
● General information : Average
● Thought
Stream : Spontaneous
Form : No FTD Present
Content : Worrying, suspiciousness
Possession : Not Present
● Mood
Range : Decreased
Reactivity : Not Present
Communicability : Present
Mobility : Not Present
● Affect : Blunt Affect
● Hallucinations : Not Present
● Trance & Possession : Not Present
● Judgment
Personal : Impaired
Social : Impaired
Test : Impaired
● Insight : Grade II

PSYCHOLOGICAL TESTS

TEST SCORE INTERPRETATION

Brief Psychiatric Rating Scale 68 Significant

Beck Depression Inventory 33 Severe Depression

GRID HAM-D 17 18 Moderate Depression

PGI- Health A 8 50.00 % Moderate physiological distress

Questionnaire
B 14 63.63 % Severe psychological distress

Total 22 57.89% Moderate physiological and

psychological distress
 SUMMARY

Mrs. P N 55-year-old female belonging to MSES of urban area of Haryana, living in a joint family was
presented for comprehensive psychological evaluation with the chief complains of pervasive sadness,
anxiousness, self-doubts, guilty feelings, stress, irritability, social withdrawal, forgetfulness, increased
sleep, loss of appetite and dry mouth.

On MSE, her general appearance was appropriate, manner of relating was guarded, rapport was
established with minimal eye contact. Speech was coherent and relevant, slight impairment in the
memory, attention was aroused and sustained, intelligence was average, concrete thinking and
impairment in social and test judgment, oriented towards time, place and person. Thought content
included suspiciousness, somatic concerns, feelings of hopelessness. Mood range was decreased with
blunted affect. Insight level of Grade II was present; PGI -HQ indicated moderate range of
Psychological and Physiological Distress; BDI-II and HAM-D17 indicate severe depressive symptoms,
BPRS indicative of significant psychotic features. The protocol goes consistent with the provisional
diagnosis of Recurrent Depressive Disorder with psychotic symptoms.

Recommendation: The client has been recommended with psychotherapy and intensive counseling
sessions.

Follow-up: The client could not come for further sessions on the said date.

Dr. Amit Dwivedi

Psychologist