CASE HISTORY – 01

(03 SEPTEMBER 2022)

Name : Mr. T M

Age : 53 years

Gender : Male

Marital Status : Separated

Education : Graduation

Family Type : Nuclear Family

Occupation : Stock Marketing

Religion : Hinduism

Socioeconomic status : MSES

Locality : Urban

Informant : Not Available

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. T M, 53-year male, separated, belonging to MSES urban area of Panchkula, Haryana living in a
nuclear family was presented for comprehensive psychological evaluation with the chief complaints
of aggressive behaviour and fear of all kinds of pins and needles leading to interpersonal conflicts
among the family members. On detailed interview, the client mentioned an incident in the year 1998
one of his colleague swallowed a pin mistakenly and due to this accident he passed away; the client
developed a fear of all pins and stapler pins. He mentioned that after this particular incident he
remained in constant state of anxiousness and disturbed and kept checking all documents and paper
for presence of any kinds of pins, for which he took treatment from Chandigarh and was treated with
Obsessive Compulsive Disorder.
He mentioned the he lived in a joint family when he got married, but due to some family tensions he
and his wife started to live in a separate house. He also stated that there were a lot of issues with the
familial adjustments and they got separated in 2003 and a year later his wife got the custody of their
children. The separation caused him lot of grief and he started to remain aloof. He tried to meet his
children but his wife didn’t allow them to meet. After his separation he started to live with his
parents; the client mentioned that he had arguments with his father on regular basis on the issue of
cleanliness. In 2012, during an argument with his father, he mentioned that his father tried to choke
him after which the client got physically and verbally aggressive with his father.

Onset : Insidious
Course : Continuous
Duration : 24 Years

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 mentioned in 2001 he was diagnosed with OCD and started seeking treatment from
Chandigarh. In 2010 he was bought to Manimajra at the hospital but he was not able to recall the
reason for his admission at the hospital. Again in 2012, the client was admitted at the hospital for his
physically aggressive with his father. In 2013, he was admitted in Pune for aggressive behaviour. His
treatment continued till 2018.

Past Medical History : Not Significant

Family History:

The client is the youngest amongst the three siblings. He currently resides with his father. His mother
passed away in 2017. He got separated from his wife in 2003. He has two children, and elder
daughter and a younger son, whose custody was taken by their mother. The client mentioned that he
had some major issues with his father, though most of their issues were related to household chores.

Personal History:

Birth and Developmental History : No birth and developmental history could be obtained as
biological parents were not present at the time of the interview.

Educational History:

The client did his schooling from Chandigarh. He got graduated in 1989 and pursued post graduate
diploma in marketing and sales management in 1992 from Chandigarh.

Occupational History:

The client started to work as a medical representative for a pharmaceutical company in Panchukla
and was transferred to Faizabad. the client faced some troubles with regard to his job as his wife had
her first conception. In 1998-99, he worked in a private organization, but left due to disturbed
familial relations. He invested in stock market; due to collapsing of stock market he suffered huge
loss. In 2003, he worked for an Ayurveda Healthcare company. Later in 2006, he was working as a
branch manager in private life insurance company. The client later shifted to another insurance
company in 2009, where he worked for few months. Currently he has been running his own business
of stock marketing.

Marital History:

The client had an arranged marriage in 1994; He has two children, a daughter and a son. Due to
turbulent conjugal relationship, they got separated in 2003 and his wife got the custody of their
children.

Mental Status Examination

● Language of the interview : Hindi

● Time taken : 20 minutes
● Level of consciousness : Alert
● General appearance and behaviour
● Handedness
● Rapport
● Eye contact
● Facial expressions
● Attitude towards the examiner
● Manner of relating
● Motor activities & behaviour
: Appropriate
: Right-Handed
: Established with ease
: Maintained
: Minimally Expressive
: Co-operative
: Relaxed
: Voluntary, Goal-Directed movements

● Speech : Relevant & Coherent

Volume : Normal
Pitch : Normal
Tone : Normal
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 : Circumstantiality
Form : Derailment
Content : Worried, Anxious
Possessions : Not present
● Mood
Range : Decreased
Reactivity : Not present
Communicability : Present
Mobility : Not Present
● Affect : Normal
● Hallucinations : Absent
 ● Trance & Possession : Absent
● Judgment
o Personal : Slight Impairment
o Social : Intact
o Test : Impaired
● Insight : Grade II

PSYCHOLOGICAL TESTS

Mini Mental Status Examination

DATE 29-08-2022 04-09-2022 09-09-2022

Orientation 10 10 10

Registration 3 3 3

Attention and concentration 5 5 5

Recall 3 3 3

Language 8 8 8

Copying 1 1 1

TOTAL 30/30 30/30 30/30

Sr. No. Tests conducted Score & Interpretation

2. Brief-Psychiatric Rating Scale

3. Positive and Negative Syndrome Scale

SUMMARY

Mr. T M, separated 53-year-old male, belonging to MSES urban area of Panchkula, Haryana living
in a joint family was presented for a comprehensive psychological evaluation with the chief
complaints of agitation, hostile behaviour, suspiciousness, interpersonal conflicts, and belonephobia.
According to his MSE, the rapport with client was established, he was calm and cooperative, eye
contact was maintained, his memory was intact, intelligence was average, mood range was
decreased, judgement was intact, attention was aroused but had difficulty in sustaining it, no other
cognitive disorganization observed. The insight Grade II was present; the client accepted that he has
some psychological issue but denied for the treatment.

Recommendation: The protocol goes consistent with clinical impression for Schizophrenia. He has
been advised for psychoeducation, pharmacotherapy and intensive intervention.

Follow-up: The client was admitted to the hospital and underwent through psychoeducation, where
the focus was to educate the client about the disorder. The client further came to counselling
sessions.

The client’s family also given family therapy sessions in order to resolve conflict amongst
themselves and to maintain cordial relationship.

Dr. Amit Kr. Dwivedi

Psychologist