Assignment 1

CASE HISTORY
1. Identification Data
 Name: RV
 D.O.B: 13th February 1998
 Age: 24
 Sex: Female
 Education: Bachelors of Arts in Fashion Designing
 Occupation: Student
 Marital Status: Single
 Family Type: Nuclear
 Religion: Hindu
 Domicile: Rural
 Socio-economic status: Middle class
 Informant (s): RV roommate
 Contact no: 99347821
 Source of referral: None
 Case Examiner: Divia Raina
 Case Supervisor: AC

2. Chief Complaints
 As per patient: For the past two months
 “Feeling very sad”
 “Feeling hopeless”
 “Worried about future”
 “Not able to shower everyday”
 “Don’t brush my hair or teeth”

As per informant: None

3. History of Presenting Illness
The client reports feelings of sadness, feelings of hopelessness and worry about
her future for the past two months. She further mentions that it began when she
had failed her college exams and had to repay her college loan. Moreover, it has
progressed till now and client is unable to cope to the point that she finds it
difficult to get up from her bed and perform personal hygiene tasks. In this case,
the predisposing factor might be the financial situation of her parents. As she
mentions that they are not “financially well off” and had to endure hardships to
get her into college. The perpetuating factors are seen to be her spending habits,
as she often engaged in impulsive shopping and gambling, which would lend
her broke all the time. The precipitating factors would be her failing the college
exams and being unable to repay the loan that is due soon. As she is unable to
find a job without a degree and tell her parents. She mentions that they would
“not take it well” as they are not financially sound.

 Biological Functioning
 Sleeping: Increased

Ms RV mentions that she spends majority of her time in the bed. She is finding
it difficult to get up, as she feels fatigued all the time. So, she ends up sleeping
for a greater number of hours. She mentions that she finds the bed
“comforting”.

 Appetite: Decreased
Ms RV mentions that her appetite has “taken a dive” from before. As before,
she loved trying various cuisines and was particular about eating at appropriate
times. Now she eats the bare minimum and at odd times.

 Sexual functions: Unchanged

 Personal care: Negligent
Her clothes appear to be wrinkled, not clean, a few stains were visible and worn
for a quite some time. Her hair was not brushed and was placed in an untidy
bun. Her nails were chipped and appeared to have been bitten. It is apparent that
she hasn’t showered in quite some time.

4. Treatment History of Present Illness

Ms RV has availed some form of treatment for her present illness in the past

 Treatment: Fasting, participating in havens and pujas to get rid of “buri

naazar”
 Nature of treatment: Faith treatment
 Place: 42 Madhav Apartments, 4th floor, Ganesh Peth Lane, N.C. Kelkar
Road. Opposite Plaza Cinema, Dadar (West), Mumbai
 Duration: Two weeks
 Adverse effects: None
 Reason for compliance: Lack of insight, was willing to try anything to turn
her situation around.
 Reason for discontinuing: Insufficiently treated symptoms. Ms RV
roommate convinced her to see a clinician and had taken her to the hospital.

5. Past History of Illness

 Medical/Surgical Illness: None
 Past Psychiatric History: None

6. Family History
 Occupation of Father: Engineer
 Occupation of Mother: Teacher
 Consanguinity between parents
Ms RV replied “My parents had a great marriage and relationship. It is one of
mutual respect and trust. They loved each other a lot. I love their relationship.
There wasn’t an ego clashes between them, both adjusted well with each other.
When disagreed at something, they would have a discussion, not duke it out like
parents I know. I have never heard them fight.”
 Family members living-dead
Ms RV replied, “My grandparents (both paternal and maternal) passed away a
long time ago. Same with my great grandparents.”
H/O mental illness in the parents (both paternal and maternal).
Ms RV replied “None that I know of.”
 Treatment details: N/A
 Client relationship with parents
Ms RV has a good relationship with both her parents. Although they face
financial constraints, she mentions that they would try their best to provide all
the comforts and facilities for her. They never discouraged her from anything
and were always supportive of her choices.

 Overall attitude

Her overall attitude towards her family, is that of affection. She mentions
having a close relationship with her maternal and paternal grandparents as well.
Her parents are a pillar of strength for her.

 Rituals: Present

When questioned about the presence of family rituals, she replied “Every
Sunday we visit the temple and eat breakfast in a nearby restaurant. On
birthdays my mother makes yellow rice with fried potatoes, which is my
favourite”

7. Personal History
 Perinatal History
 Nature of delivery: Natural birth
 Antenatal, natal and post-natal complications: None
 Developmental milestones: Achieved

 Childhood History
 Presence of childhood disorders: None
 Client reports to having good relation with friends.
 Client reports to having good relations with peers.

 Educational History
 Age of entry in school: 4 years old
 Class of entry in school: Kindergarten
 Progress in studies: Bachelors of Arts in Fashion Designing
 Involvement in school: Took part in several extracurricular activities.
Ms RV mentioned that she was a constant fixture in every annual day function,
she would either dance or act in a play.
 Relations with authority: Never challenged authoritative personnel, was
afraid to do so. Maintained a relationship of mutual respect.

 Relations with peers: Had several friends, was the center of attention, was
part of a large group. The client is still in touch with her school friends.

 Disciplinary problems: None

 Failure in any grade: None

 Discontinuation or drop out (with reasons): N/A

 Occupational History
She is currently searching for a job, as she needs to pay off her college loans.
But is unable to secure one as she lacks a degree (failed her exams).

 Menstrual History
 Age of achieving menarche: Thirteen
 Current menstrual cycles: Regular
 Associated physical/physiological problems: None
 Overall attitude regarding menstruation
When examiner questioned her attitude regarding menstruation, she replied that
when younger she found it unpleasant and unnecessary. The reason being she
used to be in constant pain and she found it difficult to tolerate, especially in
school. Sometimes would spend the day in the nurse’s office, to ‘sleep the pain
away’. Currently, she still finds it bothersome, but has figured out some ‘hacks’
to make the experience more bearable.
 Sexual and Marital History
 Sexual activities: Absent
Ms RV was comfortable sharing details regarding her sexual history. She
mentioned that for the past two months she has not engaged in any sexual
activities.
 Attitude towards sex
“It is a natural phenomenon. It exists and that’s it.”
 Age at marriage: Neither currently nor previously married.
 Parental consent for marriage: Neither currently nor previously married.
 Personality of spouse: N/A
 Role allocation between couple: N/A
 Sharing of responsibilities and decision making: N/A
 Premarital/ extra-marital relations: N/A

 Premorbid Personality
 Attitude towards self: Poorly and self-critical
Ms RV feels poorly towards herself. She mentions that she has become critical
of everything of what she has done in the past and in the present. She mentioned
that she was not like this before.
 Attitude towards others and world: Neutral
She replied, “After being burned so many times, by people I hold dear. I feel
like I need to re-evaluate my attitude towards others and world. Right now, I
feel nothing.”
 Interaction patterns and sociability: Altered
“Before this event, I was quite the social bird. But now I stay in my house more.
I used to hang out with my friends in the weekends, take two-day trips and plan
annual holidays together.”

 Sense of responsibility: Increased

“Ever since I failed my exams and the due date for my loan is near, it feels like
someone has woken me up from this haze I was in. I feel the pressure to get a
job to pay off the loans as I know that my parents won’t be able to do so”.
 Predominant mood: Sadness

 Attitude towards criticism: Bothered by it.

“Before I was not too bothered by it. I took it in a good manner, as a way to
grow as a person. Now I can’t handle it, because I know I am not doing the right
things, not taking my responsibilities seriously, which is why I expect criticism.
Receiving it now, feels like a stab to the heart”.
 Attitude towards moral values: Normal

 Attitude towards adjustment: Altered

“After creating such a mess of my life, I have no choice but to adjust to my
current circumstances. So, I can either make peace with it and learn to adjust or
rebel. I chose the first, I cannot hurt my parents. I don’t mind lowering my
living standards till I find a way to repay the loans”.
 Attitude towards hobbies/interests: No longer finds it interesting.
“Not interested in it anymore. I loved to dance, but now I just don’t have the
headspace anymore to indulge in this. I have pressing issues; I can’t dance away
my problems”
 Attitude towards substance abuse: Altered
“Normally I do not condone substance abuse. But realized there are several
reasons as to why, people do so. To get rid of pain, to go to sleep, just to forget
who they are and for the sweet release from life. I understand them now, if I
was brave enough too, I would try to using pills to end myself.”

Diagnostic Formulation for Case History

RV (she/her), 24, cis-gendered, Hindu, unmarried, female of middle socio-
economic status coming from a rural background of Assam with an unadjusted
premorbid personality with no contributory and family history. Comes with two
months illness characterized by extreme sadness, inability to maintain personal
hygiene, loss of interest in activities feelings of hopelessness and worry about
her future with insidious onset, continuous course and deteriorating progress.
 Mental Status Examination

1. General Appearance

1.1. General Physical Appearance: Unkempt and untidy

Body build: Average
Hygiene: Adequate
Grooming: Neglected
Clothes: Unkempt
Hair: Dishevelled
Posture: Slouched
Fingernails: Negligent

Ms RV had an overall unkempt and untidy physical appearance. Her clothes

were loose fitted, wrinkled, unclean with a few stains. Although she was
appropriately dressed in accordance with the setting (hospital), it was dull in
color, mostly dark grey. Her hair appeared to be unclean and unbrushed,
placed in an untidy bun. Her nails were chipped, with dirt underneath the
fingernails and some appeared to have been bitten. She had bloodshot eyes,
dark circles on her face, had dried black mascara at the corners of her eyes,
some remanets of a black eyeliner on her upper eye lid. Her posture was
slouched, placed hands on her lap, head slightly bent and shoulders were
slightly raised in the session, as she was sobbing. She did not have any
tattoos, wounds or ornaments.

1.2. Touch with surroundings: Present

Ms RV was asked some test question, which she had answered correctly.
The questions are as follows: -
a. “Who am I?”
b. “Where are you now?”
c. “What is my name?”
d. “What is the name of the hospital?”
It indicates that she is aware of her surroundings.
1.3. Eye contact with examiner: Partial
Throughout the session, she had partially maintained eye contact, she either
would look down at her lap or maintain eye contact with the examiner, both
for a few minutes at a time, as she was sobbing.

1.4. Facial Expressions: Appropriate, congruent with mood.

Her facial expressions were appropriate and were congruous with her mood,
which is sadness. As her lip corners were slightly pulled down, trembling
lips, drooping upper eyelids, eyes were looking down at her lap at times,
inner corner of her eyebrows were pulled up and together.

1.5. Posture: Slumped

Throughout the session her entire posture was closed, her back was
hunched, her knees were together and her was lowered, as if she was folding
in on herself.

2. Attitude towards the examiner: Co-operative

As she was responsive and unguarded throughout the entire session, as she
voluntarily provided detailed information (prior relationship with a married
man). She was respectful and not hostile towards the examiner, as she did
not yell and/or use abusive language.

3. Rapport: Easily established.

Easily established.
It was easily established as the client herself had readily volunteered
information, she was neither hesitant nor evasive and was seeking help.

4. Motor Behaviour: Retardation

Her motor movements were slow, as she seemed lethargic.

5. Speech

5.1. Intensity: Inaudible

As she was sobbing and facing breathing difficulties, she was inaudible. The
examiner had to ask her to repeat her responses several times.
5.2. Pitch: Low

5.3. Quality: Hoarse

Throughout the session, her voice was hoarse, as she was sobbing.

5.4. Reaction time: Decreased

Ms RV reaction time was decreased, as she sobbing and having breathing
difficulties.

5.5. Speed: Very slow

Ms RV speech was very slow, as she was narrating, sobbing and trying to
catch her breath all at the same time. She would speak two to three words at
a time and then pause.

5.6. Ease: Stammering

In the entire session, Ms RV was sobbing and trying to speak at the same
time, which might have resulted in a slight stammer.
5.7. Coherence: Incoherent
Her narration was incoherent, as it was inaudible.

5.8. Relevance
Relevant
Her narration was relevant, she only spoke to the point and did not stray to
other topics.

5.9. Goal directedness

Goal directed
As her narration was progressing, without veering from the subject at hand.
5.10. Rate of production
Scant of speech
As she was struggling to speak, as she was sobbing and experiencing
breathing difficulties.

5.11.Deviations: Absent
While speaking she had not deviated from the subject at hand.
6. Cognitive Functions
6.1. Orientation
 Time: Present
 Place: Present
 Person: Present
Ms RV had accurately responded to the following test questions for orientation
of time, place and person respectively,
 “What time is it?”
 “Where are you?”
 “Who am I?”

6.2. Attention and Concentration

 Number of days in a month
Accurate response
When questioned the number of days in a month, Ms RV had responded
accurately, that it is either thirty or thirty-one. Also, mentioned that February
has twenty-eight days, but in a leap year, the month has twenty-nine days.
 Backward counting
Accurate response
When instructed to count backwards from hundred while subtracting five
numbers, she was able to respond accurately. For instance, 100-5 =95, 95-5 =
90 and so on. She took some time to respond.

 Serial Recall
Inaccurate response
The examiner had recited the following words, umbrella, regulator, pink, glue,
frame and candle and instructed Ms RV to keep them in her memory. After
conversing with for fifteen minutes, the examiner asked her to recall those
words in the same order. Ms RV was unable to do so, as she had missed a few
items and misarranged them.
 Digit Forward/Backward
Inaccurate response
The examiner had instructed Ms RV to recall the following numbers, 8, 3, 1, 7
and 5 in the same order. The examiner ensured that while providing the
numbers, the tone was consistent, the gap between the numbers was equal and a
sound cue (for instance, tapping on table) was given to indicate that Ms RV
could begin responding. Ms RV was unable to do so, as she not recited it in the
same order.

6.3. Memory
 Immediate: Present
 Remote: Present
 Recent: Present

For immediate memory, when questioned to name five colors, she was able to
recall immediately.
For remote memory, when questioned about her home address, she was able to
recollect and recite it accurately.
For recent memory, when questioned about her last meal, she was able to recall
and answer accurately.

6.4. Abstract Ability: Conceptual

The examiner had asked the following questions to Ms RV to test her abstract
ability,
 “What is love?”
 “What is guilt?”
She provided a conceptual answer to both. The first being, a feeling of affection
to anyone or anything. The second being, feeling of a weight on her shoulders.
6.5. Intelligence

 Comprehension: Average
The examiner had read out a passage, Ms RV was able to comprehend it.
 General information: Average.
The examiner asked the following questions,
 “What is the name of the current President of India?”
 “What is the capital of India?”
 “What is the national animal of India?”
She answered all the questions correctly.

 Vocabulary: Average
The examiner asked the client to provide synonyms of knife in Hindi. She was
able to provide three correct synonyms.
 Calculation: Average
The examiner had given a few simple mathematical questions for the client to
solve. She solved it correctly.

7. Mood and Affect

7.1. Mood
 Objective: Depressed
The examiner came to this conclusion, as the client has expressed feelings of
extreme sadness, hopelessness and helplessness. Also, reports of change in her
sleep and eating patterns.

 Subjective: Sadness
The examiner asked the client to describe her how she was feeling and if she is
experiencing any biological symptoms as a result of her mood. The examiner
asked the following questions to encourage the client to provide a subjective
answer.
 “How have you been feeling recently?”
Ms RV replied that, “I feel sad and terrible all the time, to the point where it
hurts my chest. I have lost all hope and feel so helpless.”

 “How have your energy levels been?”

Ms RV replied, “I do not feel like doing anything at all. I spend most of my
time in my room, on my bed. I just feel tired without doing anything.”

 “Have you been sleeping and eating well?”

Ms RV replied, “Not at all. Like I mentioned before, I just spend the whole
day in bed sleeping, because I feel so tired. Also, I eat so little now, not even
proper meals. Before, I loved trying new cuisines, now I find that all
pointless and a waste of time.”

 “Have you felt irritable, unmotivated, angry or depressed recently?”

Ms RV replied, “Yes, I have been feeling unmotivated and depressed for
quite some time now. Not so much anger or irritated. Just feel hollow and
like I told before, just sadness.”

7.2. Affect
 Objective: Depressed, appropriate to context, congruent to the mood
Ms RV displayed emotions of sadness and hopelessness, which was appropriate
to the context of the conversation. Her facial expressions and body language
were congruent to the context of the conversation and her mood. For instance,
had a tearful expression throughout the session.

 Subjective: Hopelessness, Sadness

Ms RV stated, “I have been feeling extreme levels of hopelessness. It is difficult
to explain. I cry all the time and keep thinking about all the good times before
all this happened. I feel so helpless, I can’t fix this.”

8. Thought
8.1. Stream: Normal
Ms RV stream of thoughts is normal, it is not rapidly changing, blocked or
slow.
8.2. Form: Goal-directed

As the client’s thought form is logical, organized and easily understandable.

8.3. Possession: Normal

The examiner asked the following questions to the client to screen for thought
possession abnormalities.
 “Do you think people can put ideas in your head, without your control?”
She replied, “No. I am quite a stubborn and rational person, I do not get
swayed easily and believe sweet words of others.”

 “Have you ever felt like people have removed memories or thoughts from
your mind?”
She replied, “No, I have never felt in that way. True, I might have forgotten
some memories or thoughts, but no one is responsible for that”.

 “Do you ever feel like others can hear what you are thinking?”
She replied, “No, I do not feel that way.”
It indicates that Ms RV does not present any thought possession abnormalities
8.4. Content: Normal

9. Perception: Normal
The examiner asked the following questions to screen for perceptual
abnormalities.

 “Do you ever see, hear, smell, feel or taste things that are not really there?”
Ms RV replied, “No not really.”

 “Do you ever feel like the world around you aren’t real?”
Ms RV replied, “Not really.”

 “Do you ever feel like you have changed or that you don’t recognize the
person you currently are?”
 Ms RV replied, “No I am quite the same.”

 “Do you think this interaction is real?”

Ms RV replied, “Of course, that is a silly question.”
It can be understood from the responses that the client does not have any
perceptual abnormalities.

10. Judgement
 Social Judgement: Appropriate
The examiner asked a question which tests client’s social judgement.
 “If you find a wallet on the sidewalk while walking. What do you do?”
Ms RV replied, “I would take the wallet to the nearest police station to return it
to its owner.”
This response indicates that the client has sound social judgement.

 Personal Judgement: Appropriate

The examiner asked a question which tests the client’s personal judgement.
 “What would you do if your kitchen catches fire?”
Ms RV replied, “I would look for a fire extinguisher and put out the fire.”
This response indicates that the client has sound personal judgement.
 Test Judgement: Appropriate
The examiner asked a question which tests the client judgement in a
hypothetical situation which requires her to take steps.
 “If one of the cinema theatres exits caught on fire, what steps would you take
in this situation?”
Ms RV replied, “I would look for another exit and calmly direct everyone
towards the alternative exit, while the usher extinguishes the fire”.
This response indicates that the client has sound judgement in such situations.

11. Insight: Level 5

Diagnostic Formulation for MSE

RV (she/her), 24, cis-gendered, was unkempt and eye was partially maintained;
conscious and oriented to place and person. Rapport could be easily established.
She was able to comprehend the instructions given. Her speech was coherent,
relevant, but inaudible. Her fund of knowledge was average. Mood and affect
were congruent, he was objectively depressed and subjectively “feeling
hopeless and extremely sad”. Cognitive functioning was adequate. Her
immediate, recent and remote was intact. Has no perceptual abnormalities.
Judgement was intact. Insight was at level 5.

Diagnostic Formulation for Case History

RV (she/her), 24, cis-gendered, Hindu, unmarried, female of middle socio-
economic status coming from a rural background of Assam with an unadjusted
premorbid personality with no contributory and family history. Comes with two
months illness characterized by extreme sadness, inability to maintain personal
hygiene, loss of interest in activities feelings of hopelessness and worry about
her future with insidious onset, continuous course and deteriorating progress.
Q2. The Suicide Behaviours Questionnaire-Revised (SBQ-R) was administered
to the client. It is a self-report questionnaire, designed to identify risk factors for
suicide in adults and adolescents. Moreover, this four-item questionnaire taps
into four constructs within the suicidal behaviour domain: lifetime ideation and
attempt, recent frequency of ideation, suicide threats, and self-assessed
likelihood of future suicidal behavior. These items are rated on Likert scales of
varying lengths, wherein the total scores lie between 3 and 18.

Ms RV overall score was 13. In terms of general population her score entails
significant risk of suicidal behaviour.

Q3. Based on her case history and mental status examination, I suggest
employing the Hamilton Anxiety Rating Scale (HAM-A) and Hamilton
Depression Rating Scale (HAM-D), as she shows signs of depression and
anxiety. She reports extreme sadness, feelings of hopelessness and worry about
her future. Further clarification is required to confirm the diagnosis. The
clinician can also the Rorschach test, to gain insight on the thinking patterns and
emotional functioning of the client.

Q4. As Ms RV is of significant risk of suicidal behaviour, measures need to be

taken to ensure all harmful items are not near her grasp. Moreover, to make she
is not alone at any given time. Art therapy and CBT sessions can be scheduled
in the week, depending on the availability of the client.