CASE VIGNETTE

Arushi, a 23-year-old unmarried female student from Baroda, Gujarat, presents with
symptoms indicative of a psychological condition. Currently pursuing her postgraduate
degree, Arushi has been experiencing chest palpitations for four months, difficulty falling
asleep for eight months, restlessness for one year, decreased appetite for three months,
decreased social interaction for one-year, excessive worry for one year, and crying spells for
nine months. The onset of these symptoms was insidious, with a progressive course over the
last year.

Arushi has a history marked by significant stressors and challenges. Her parents divorced two
years before she went to college, leaving her feeling unsupported and abandoned. Although
her older sister is aware of her condition and supportive, her parents’ remarriage and minimal
contact have added to her stress. Arushi’s high academic expectations and pressure to excel
have compounded her anxiety. After failing to clear the interview for her master's program on
the first attempt, Arushi took a year off to prepare again, which added to her anxiety and
stress.

Upon entering her dream college eight months ago, Arushi’s worry about her performance
intensified. She constantly feared not performing well, getting poor grades, and failing her
exams. This continuous worry impacted her ability to attend classes and study effectively.
She became increasingly restless, fatigued, and often cried herself to sleep. Her social life
also suffered as she isolated herself from her boyfriend, leading to a tumultuous relationship.
Her anxiety escalated with several embarrassing instances in college, where she lost track of
her thoughts. Her persistent worry and mental rehearsals of worst-case scenarios, including
failing her degree and ending up jobless, further exacerbated her condition.

Currently, Arushi feels persistently low, experiences chest pain, and has contemplated ending
her life, feeling that life is no longer worth living. Her academic attendance has dropped
significantly as she avoids going to college, yet she remains preoccupied with her anxious
thoughts.
 CASE HISTORY

Socio demographic details

Name: Arushi
Age: 23 years
Gender: Female
Preferred Pronouns: She/Her
Religion: Hindu
Marital status: Unmarried
Education: Post Graduate
Occupation: Unemployed, student
Socioeconomic status: Middle
Address: Baroda, Gujarat
Informants: Self and older sister

Chief complaints
 Chest palpitations * 4 months
 Difficulty falling asleep * 8 months
 Restlessness * 1 year
 Decreased appetite * 3 months
 Decreased social interaction * 1 year
 Excessive worry * 1 year
 Crying spells * 9 months

Presenting problems
 Onset: Insidious
 Course: Progressive
 Duration: 1 year
 Predisposing Factors: Parental divorce and high academic expectations
 Precipitating Factors: Failure to clear the Master's interview on the first attempt
 Perpetuating Factors: Continuous worry about performance and future, sleep
disturbances, social isolation, and family conflicts.
History of presenting illness
1 year back- Patient had just completed her undergraduate degree and was preparing for her
masters which happened to be the same college where she completed her under graduation.
She prepared very had for the interview and would worry constantly about whether she would
get in or not as the course she was applying for highly competitive for the Masters course.
She did not clear the interview in the first try and did not want to apply to any other college.
She then decided to take a drop year and prepare for the interview.

8 months back- Patient entered her dream college after taking a drop. She was very happy
with her college in UG and wanted to complete her masters from the same college as well.
Although she got admission in her dream college, she constantly worried about not being able
to perform well there, not getting a good grade and not being able to pass her exams.

6 months- Ever since then, her worry was not able to stop. She would not be able to sit in
class or even study for exams. She would feel restless, and tired and often cried herself to
bed. She often paces around alone in her PG corridors at night. She also started isolating her
from her boyfriend, which caused fights between them. It soon became an on again off again
relationship.

3-4 months back- She had several embarrassing instances with her friends and college
professors where she lost track of what she was trying to say. At night she describes her brain
would not shut off. She would be so worried and tense all the time, that even the thought of
her state in college would make her want to go use the washroom. She started mentally
rehearsing the worst-case scenarios in head that include her being thrown out of college, and
not getting a degree and a job and eventually land up on the streets.

Currently- Patient reports feeling low all the time, has recently also experienced chest pain.
She contemplates ending her life because she feels life is not worth living anymore. She
avoids going to college and now has a low attendance percentage but still finds herself
preoccupied with these thoughts.

Negative history:
 No hallucinations or suspicions
 No diabetes, TB, STI’s
 No hearing of voices
  No history of substance abuse, suicide or mental illness

Past history: No history of psychiatric illness in the past

Past medical and surgical history: No significant medical and surgical history

Family history
 Type of family: Nuclear
 No of family members: 5
 Family concept about illness: Her family is not aware about her illness; they are
hardly in contact with their children anymore as they are divorced. Her older sister is
aware of her condition and is willing to aid for any kind of help she needs
 Family stress: Her parents are divorced; they are now remarried and maintain very
less contact with their children
 Her parents very divorced 2 years before she went to college and at the time she felt
unsupported and abandoned
 Her sister, is 35 is working as in a Non-profit Organization in Delhi and is
economically well of, enough to take care of her sister.
 Every time the parents come together to spend time with the children, it becomes even
more overwhelming for the patient as they fight quite often, always blaming and
calling each other names
 Substance abuse: Her father is a regular smoker
 Living arrangement: The patient is currently living in a PG in Baroda and her sister
stays in Delhi in a 3-bedroom flat. During her holidays, patient lives with her sister in
Delhi
 Head of the family: Older sister
 Chief caregiver in the family: Older sister
 Chief decision maker: Older sister
 Father of patient has history substance abuse

Personal history
 Birth history (from her sister): was born at 9 months by normal vaginal delivery and
cried immediately after birth. All milestones were attained at the right time.
 Childhood history: No history of hyperactivity, inattention, impulsivity, stealing, lying
or disobedience
 Academic: Started schooling at 3 and a half years of age and education and currently
in pursuing her Master’s degree. Patient had a high academic record in school, but
was average student in college. She is well behaved and does not receive complaints
from teachers.
 Menstrual history: Onset during the age of 13, gets periods regularly
  Sexual history: Currently seeing someone, has had no sexual relations, no history of
previous partners, sexual history or masturbation. She is currently pursuing a long-
distance relationship with her classmate from school whom she was good friends
with.
 No history of abuse of alcohol, tobacco or drugs

Pre morbid personality

 Patient was an extrovert, was involved in extra curricular activities in school and
college. She liked going to parties, catching up with friends and attending other social
gatherings.
 Was part of the band in college
 Loved her boyfriend immensely and was in a stable happy relationship

Mental status examination (MSE)

1. General appearance and behavior

 A young woman with average built, normal gait and posture
 Face looks fatigued and dull
 She is properly groomed and dressed
 Eye contact was established and sustained
 She was well oriented to time, place and person
 Signs of heavily bitten nails
 Scratched skin near nail beds
 Always fidgeting
 Dark circles prominent

2. Speech
 Spontaneous
 Coherent
 Relevant
 Tone was normal
 Volume increased
 Rate increased

3. Mood
 Fear
 Sad
 Affect- Worry
 4. Thought
 Stream: Increased flow
 Form: No distress
 Possession: No distress
 Content- Repetitive thoughts of “why is this happening to me:
 Impression: guilt and worry
 No delusion of thought

5. Perception
 No hallucinations
 No errors in perception

6. Attitude towards examiner

 She was calm and cooperative throughout the session

7. Cognitive functions
 Orientation: Patient was oriented to time, place and person
 Attention and concentration: Arousable and sustained
 Memory: Immediate, recent and remote memory were intact
 Intelligence: Adequate abstract thinking
 Comprehension intact

8. Judgment
 Patient behavior in personal and social judgment are intact

9. Insight
 Present

Provisional diagnosis
 Generalized Anxiety Disorder