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Final case con.pptx
1. CASE CONFERENCE
Presenter: : Dr Abhishek
: Dr Tafheem kanwar
Chairperson : Dr Purushottam
Coordinator : Dr Ravi Parkash
2. Aim
◦ To discuss the psychopathology of a young male presenting with psychotic symptoms.
3. Socio Demographic Profile
◦ Patient A, 18 years old unmarried male, educated up to 12th class, student, belonging to Hindu
nuclear family of lower socio-economic status of rural background of Mahendragarh Haryana.
4. INFORMANT
◦ Patient himself
◦ Patient’s mother, 40 years old, 10th pass, homemaker.
◦ Old records
◦ Information adequate and reliable
5. CHIEF COMPLAINTS
◦ According to patient-
◦ डर लगता है ।
◦ According to informant
◦ गुस्सा करता है
◦ सोता कम है
◦ शक वहम करता है 3 months
6. ◦ Total duration of illness – 2 years
◦ Current episode 3 months
◦ Onset – acute
◦ Course – episodic with complete inter episodic recovery
◦ Precipitating factor- ?Unsatisfactory result
◦ ?non adherence to medicine
◦ Date of admission : 12/11/21
◦ Admitted as High Support Admission under MHCA 2017
(Section 89)
◦ Nominated Representative- mother
7. HISTORY OF PRESENT ILLNESS
◦ Patient was apparently a symptomatic 3 1/2 months back and was maintaining well on
medication then his result for class 12 from Haryana open board but announced and he scored
76% as per attended patient was unsatisfied with his mask as he conveyed his concerns and was
then appreciated by family members but he remained upset about for 2 to 3 days. After that he
did not talk much about it and continue to follow his daily schedule where he would wake up at
around 7 AM in the morning he would have breakfast and then would visit nearby ground to
play outdoor games like cricket and football along with his friends, he would return after 2 to 3
hours and would take a bath would have lunch and then would take some rest watch TV or use
his phone.
8. ◦ In the evening he would help his mother in getting Vegetables and groceries from market and would
help his father in taking care of his farm cattle and other farm work he was having cordial
relationship with his siblings and parents.
◦ Three months back he suddenly stopped taking medication stating that he is alright and does not
require any medication as he is perfectly fit, the mother tried to convince him and asked to first
consult the treating doctor and must take their advice but he did not followed. within one week his
family member noticed that the patient is getting irritable on minor requests. He would indulge in
arguments with his mother and sister unlike his previous self as he used to talk with them in a very
respectful manner. At first thought that it is because he might be upset with his result and was taken
in a lighter vain and ignored but his irritable behaviour worsened over two weeks as He would have
a violent bust out on trivial issues. His irritability increased as he had become verbally and physically
abusive , where he would try to harm his family members.
9. ◦ After 8 to 10 days or stopping medication mother noticed that his sleep is also disturbed as he
would not sleep till late night and would engage in using his phone and waking up at usual time as
previously he would sleep for about 8 to 9 hours at night and half to 1 hour at day time. over 10 to
15 days his sleep decreases for 5 to 6 hours at night with no sleep during daytime. initially he would
keep lying on his bed using his phone, watching movies but later he would keep sitting on his bed
looking around as if he is searching for something when I enquired about same he would not reply.
Since one month patient is sleeping only about 3 to 4 hours and would roam around house. He
would keep pacing from inside to outside, from one room to other, upstairs to down and if anyone
ask he would get irritable.
10. ◦ About 10 to 15 days after stopping medication patient also stopped going to the park and started to
avoid his friends when they visit them he started to stay at his home for most of the day he gradually
stopped going to market saying he heard people talking about him therefore he felt uneasy with
others over 1 to 2 weeks but will observe that patient remains fearful at home and if some stranger is
crossing their house or standing on the street he would complain mother that they are talking about
him and want to harm him and as such felt unsafe but they tried to convince him but he was not
convincible he would remain fearful and would kept on saying the same.
◦ Over the next 1 to 2 week he started to get suspicious against neighbour And family members on
several occasions he was found eavesdropping on them on being asked he would accept it and
would say Ki Meri Bari me but a good day Ho Tum Mujhe Pata Hai Mujhe Marna Chahte ho he
would allegate his family member of being given left over stale food and ask his mother to prepare
fresh dough and then to make rotis in his front and when served he would refuse to eat and ask
mother to first eat it in order to assure that she has not added anything harmful to it.
11. ◦ Gradually his appetite also decreased from three chapatis per meal and would have 3 meals per day
and snacks in between to 1-1/2 Chapati in 2 meals. Somedays he would ask his mother to prepare
food for him and he would left the food just after tasting it saying it taste different. For past one
month he did not eat the food prepared by his mother or sister when was having chips Kurkure and
burger along with fruity he purchased himself from nearby shop.
◦ He started to remain aloof and did not interact much with other family members. for the past one
month he also started to complain of hearing voices which are engaging in a conversation involving
a man and a woman whom he does does not recognised as familiar. the voices are threatening him
to cause him harm, injuring him by cutting his legs. Often he would talk to him self and shout in
distress and when mother asked he would not reply. on many occasions when mother ask him to
have food He would refuse Saying the voices are asking me not to eat it as they will harm me if I eat
food and sometime he would say that the voices are telling him not to have food as it is being
poisoned. Invent mother try to request him he would hit her and would push her back Violently after
1 to 2 hours he would come to mother apologising and saying he did not wish to but someone else
is making him to do so and he could not resist it.
12. ◦ For the past two months also noticed him washing his hands 10 to 15 times in a day and taking 7 to
8 minutes each time he would wash his hands up to the elbows and legs up to the knees with soap
when enquired patient told that he He is washing hands as he touched unclean surface. He would
take more than usual time in taking bath. But for one month he had stopped taking care of personal
hygiene as he would not trim his hair and nails would not get any bath but continued to follow the
practice of washing hands and legs multiple times in a day. And when mother asked he would get
physically and verbally abusive towards her.
13. NEGATIVE HISTORY
◦ No h/o of Head injury, loss of consciousness,ear nose throat bleed, fever, neck rigidity, vomiting,
◦ No h/o substance intoxication.
◦ No h/o cheerful mood, overactivity, overtalkativity, overspending,
◦ No h/O of pervasive sadness of mood ,suicidal talks, crying spells.
14. Past History
◦ No h/s/o TB, HTN, Epilepsy, Jaundice, Seizure disorder, Asthma, Thyroid dysfunction
◦ No past history of any surgeries performed
◦ Past history of psychiatric illness present.
15. ◦ August 2019-March2020
◦ Symptoms characterised
◦ Suspiciousness
◦ Fearfulness
◦ Decreased sleep
◦ Hearing of voices
◦ Muttering to self
◦ Admitted in PGIMS Rohtak from 16/1/2020 to 9/3/2020
16. Treatment history
Month and year Symptoms Treatment Response Side effects
January 2020 Suspiciousness
Fearfulness
Decrease
sleep,hearing of
voices, muttering
to self
Tab risperidon
2mg bd
Tab clonazepam
0.5 mg bd
No Improvement
in target
symptoms
EPS
February 2020 Some
improvement
Repeated
handwashing
Tab olanzapine 10
Cap fluoxetine 20
mg bd
Improvement in
target symptom
March 2020-
august2021
Same
17. FAMILY HISTORY
40 yr, 10th pass,
homemaker
20yr , BA 1st
year
15yr, 9th stand.
45 y, 8th pass
Talking to self
Hand gesturing
Disorganised
behaviour
18. ◦ Patient belongs to a Hindu nuclear family of middle socio-economic status residing in rural
background of Mahendragarh.
•He currently resides with his parents and two sisters at their own home.
•He is second among three siblings.
•No h/o suicide/ abscond/ in family members
•Chief care giver – mother
•Chief decision maker- mother
•Chief earning member- Father
19. Attitude of the family toward illness
◦ Family members consider it to be a mental illness and believe it can be treated by a psychiatrist.
◦ In the first episode they took patient to faithhearlers and when no improvement was noticed, consulted
psychiatrist for his illness.
20. PERSONAL HISTORY
Birth and early development history
•Full term vaginal delivery at home,
•No ante-natal, intra-natal or post-natal complications,
•Cried immediately at birth,
•No h/o postnatal illness or admission in the hospital
•Milestones of development achieved at proper timing.
21. ◦ Behavioral and physical illness during childhood–
•No h/o sleep disturbance, temper tantrums, thumb sucking, nail biting, bed wetting, stammering, tics
and mannerisms and fear-states.
•No h/o conduct disorder.
•Had good relationship with parents and sibling and obeyed commands.
•No h/o childhood medical illness.
22. ◦ Educational History
◦ Started education at age of 5 years
◦ Good scholastic performance
◦ 10th in 2017- 9.4 CGPA
◦ 12th in 2021- 76%
◦ No h/o bunking, bullying, complaints, suspension from school.
23. ◦ Sexual history – Did not elaborate on sexual knowledge.
◦ Substance abuse history – nil
◦ Legal history- nil
24. Pre morbid temperament
◦ Activity level- high; used to remain active
◦ Rhythmicity- regular sleep wake cycle, regular bowel movements, regular food taking habits.
◦ Distractibility- not easily distractible
◦ Approach and withdrawal- positive; would approach new situation and strangers easily.
◦ Adaptability- adaptive; easy moving into change
◦ Persistence and attention span- attentive
◦ Intensity of reaction- mild
◦ Threshold of responsive – high
◦ Quality of mood- positive; used to remain cheerful
◦ Impression- easy going child
25. General Physical Examination
◦ Patient is conscious, cooperative well built. General condition appears fair.
◦ Weight— 62kgs Height—170cm BMI – 21.5 kg/m2
◦ Vitals:
Pulse Rate- 80 bpm, regular in rhythm, normal volume, normal
character, synchronous
◦ Blood Pressure- 128/78 mmHg, right arm, sitting position
◦ Respiratory Rate- 14 per min, regular in rhythm
◦ No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal oedema.
26. Systemic examination
◦ Cardiovascular system :
◦ Inspection- no deformity or bulging present, apical impulse seen, no engorged veins.
◦ Palpation- apex beat on left 5th intercostal space on MCL and tapping in character. Carotid pulsation
felt. No thrills felt in any other areas and in carotid arteries.
◦ Auscultation- S1, S2 heard, no murmurs or other adventitious sounds heard in any area or over carotid
arteries.
27. ◦ Respiratory system :
◦ Inspection- shape of the chest: B/l symmetrical; respiratory rate- 14 per minute, regular in rhythm,
normal breathing pattern B/l movement of chest; No accessory muscle usage; no wheezing or stridor
heard; no sinus, scars, or local erythema seen; no vertebral deformities or bulging present; no engorged
veins.
◦ Palpation- no local rise of temperature or tenderness, trachea midline; apex beat on left 5th intercostal
space on MCL; B/l chest symmetrical movement.
◦ Percussion: B/l resonant.
◦ Auscultation- B/l normal vesicular breath sounds heard, no other adventitious sounds heard.
28. ◦ Per Abdomen examination
◦ Inspection- shape of the abdomen: distended; flanks not full; umbilicus- midway
between xiphisternum and symphysis pubis; no sinus, scars, pigmentation or local erythema seen; no
engorged veins; hernial sites normal.
◦ Palpation- no local rise of temperature or tenderness, no organomegaly; no inguinal lymph node
enlargement.
◦ Percussion: tympanic note.
◦ Auscultation- bowel sounds heard.
29. ◦ Central nervous system:
Patient is conscious, cooperative
No signs of neck rigidity.
Cranial nerve examination normal
No signs of cerebellar dysfuncton
Steady gait and posture
No signs of autonomic disturbances
30. Right left
Upper limb Lower limb Upper limb Lower limb
Motor functions:
Tone normal normal normal Normal
Power 5/5 5/5 5/5 5/5
Bulk normal Normal normal Normal
Reflexes Right Left
Superficial:
Abdomen
Plantar
++
Flexor response
++
Flexor response
Deep:
Biceps ++ ++
Triceps ++ ++
Knee jerk ++ ++
Ankle jerk ++ ++
31. MENTAL STATUS EXAMINATION
(18-11-2021)
General appearance and behaviour-
◦ An average built male looking of stated age, entered the interview room in steady
gate and balanced posture along with his mother , seated on offered chair
comfortabely, greeted the interviewer on being greeted, dressed appropriately
according to gender/ culture/ weather, hygiene maintained.
◦ Patient was constantly suspicious during the interview and kept asking questions
like what the interviewer writing down in the page, patient was also doubtful that
interviewer was recording the whole conversation and insisting to show the
mobile phones.
◦ No hallucinatory or stereotypic movements observed during the interview.
32. ◦ Eye to eye contact: made and maintained.
◦ Rapport: Established
◦ Reaction Time: Normal
◦ Psychomotor activity: Normal
◦ Speech – Normal rate/tone/volume
Comprehensible, Coherent, Relevant
In response to questions
33. ◦ Mood and Affect – (S) – Darr lag rha h
(O) – irritable
◦ Thought –
◦ Form - NAD
◦ Stream - NAD
◦ Content - [Speech sample]
◦ Possession – [ Speech sample ]
◦ Perception – [ speech sample]
34. ◦ Q. Namskar ,kaise ho aap ?
◦ A. Main thik hoon
◦ Q. Accha fir aspatal aana kaise hua ?
◦ A. Dikkat ho gai hai.
◦ Q. Kis trha ki dikkat ?
◦ A. hamesha darr laga rhta hai.
◦ Q. kis baat ka darr?
◦ A. Yahi k log mujhy marna chahty hain, sab mere khilaf ho gaye hain. Mummy bhi unhi logo ki
baat sunti hai. Behan bhi mummy k saath mil kar mujhy gaaliya nikalti, mere khilaf baatien
Sab mil kar mujhy maarna chahty hain.
35. ◦ Q. Sab log ? Mummy aur behan k alawa aur kaun?
◦ A. bahar k log, sab log miley hue hain. Mummy aur behan bhi inki baato main aa gai hai. Is
wajah se in logo se baatien karti hai aur mere khilaf sab mil kar saazish karty hain. Is liye
bahar jaana bhi kam kar diya hai , ghar par hi rhta hoon.
◦ Q. Par jo log bahar k hain, jo tmhy jaanty hi nhi wo tmhe kyu maarna ya nuksan pauchna
chahngy?
◦ A . Wo mujhy nhi jaanty is liye toa mujhy maarna chahty. Sab mere khilaf hain,Sab mujhy achy
janty nhi, koi jaan pehchan nhi hai, is liye marna chahty hain. Mummy aur behan k karan mere
bare main inko galat jankari hai, aur isi wajah se mere pichy pare hain.
36. Q. Tumne kabhi khud se kuch dekha ya suna hai jisse pata chale k ghar wale ya baharwale
tmhre khilaf hain ya tmhra nuksan chahaty hain?
A. Haan meri behan aur meri maa ko mere khilaf baatien karty suna hai, hmesha galiyan nikalti
rhti hai. Mere khane ko jhutha kar k deti hai. Aur mujhy ye bhi lgta hai k khane mai kuch
kar deti hai.
Q. Tmne dekha hai khane mai kuch milaty hue?
A. Nhi dekha nhi hai, par mujhy hmesha khane ka swad kuch alag sa lgta hai, issi se pata chala .
liye hi maine ghar par khana nhi khata aur jab khana ho toa khud se bna leta hoon. Sab
hain k khana kyu nhi khata, ab marne se accha hai k main bhukha rahu.
37. Q. Par tumhri maa ya tmhri behan aisa kyu karengi?
A. Mujhy nhi pata , bas mujhy ye maloom hai k mere maa aur behan mujhy marna chahty hain,
meri bua ne inhe mere khilaf bola hai.
Q. Bua kyu karengi aisa?, kuch wajah toa hoga na?
A. Wo mujhy nhi maloom
Q. Accha par mujhy abhi bhi samajh nhi aaya ki bahar wale log tmhy kyu pareshan karty hain?
A. Sab mujhy achy se janty nhi, koi jaan pehchan nhi hai, is liye marna chahty hain.
Q. Ye toa koi karan nhi hua , k jaan pehchan nhi hai toa kisi ko koi maar dega, is trha toa bahut
se log ek dusre ko nhi jaanty.
A. Nhi mujhy achy se maloom hai k sab log mujhy mil kar maarna chahty hain, maine bahut
dekha hai , k mere taraf dekh kar meri baatien karty hain, mere taraf ishara karty hain aur kai
baar toa apne car ko mor kar mere peeche aaty hain.
Impression:- Delusion of Persecution
38. Q. Tum jo ye har baar bta rahy ho k log tmhre bade baat karty, tmhy dekh kar ishara karty hain.
Kabhi kuch tmne suna bhi hai, ho skta hai wo khud main baat kar rahy ho, tmhre liye nhi kar rahy ho?
A. Sunne ki kya jarurat , unko dekh kar hi pata chal jata hai, hmesha jab dekho toa mere taraf dekh
baatein karty hain, isare karty hain, iska matlab kya hua
Q. Accha par jab baatein karty hain, toa unko suna bhi higa, kya bolty hain wo?
A . Nhi, mujhy darr lgta hai, kabhi itne paas nhi gaya ki unki awaaz sun sako, par meri maa aur behan
suna hai, gaali nikalty, mere khilaf bolty.
Q. Tmhre alawa kisi aur ne bahar wale log ko tmhre khilaf bolty ya koi shazish karty dekha hai?
A. Haan mere bade main radio par khabar aai thi, log mere khilaf bol rahy thay. Mera video bhi
Instagram par aaya tha, jisme mere khilaf sabhi bol rahy thay.
39. ◦ Q. Radio aur insta par agar is trha k koi baat hua hai toa aur kisi ne bhi jarur dekha hoga?
◦ A. Haan jarur dekha hoga par koi bhi nhi btyga ,sab miley hue hain.
◦ Q. Par tmhre bade radio par ya insta par khabar kyu aayga? Ye kaise possible hai?
◦ A. Sab mere khilaf plan bnaye hue hain, sab koi mil jaye toa kya nhi ho skta ,sab logo ne mil
hi ye kiya hai.
◦ Q. Tmhy nhi lgta k radio ya insta par genrally famous logo ki news aayegi, tmhy lgta hai k
tumne kuch aisa kiya hai k tmhri khabar aaye?
◦ A. Mujhy ye nhi pata k main kitna famous hoon , par jab koi kisi ko maarna chahy toa koi kuch
bhi kar skta hai, sab log mil jaye toa sab jgha khabar faila skta hai, yahi mere saath ho rha.
40. ◦ Q. In sab baato ka radio par khabar ka insta par news ka koi sabut hai tmhre pass?
◦ A. Main sabut jama krne wala nhi hoon, aur radio ka sabut kaise lau, wo toa khabar aaya aur
chala gya
◦ Q. Accha fir Instagram wala video dikha do.
◦ A. Mera phone lock hai aur main password bhul gya hoon, ek dafa khul jaye toa dikha dunga.
◦ Impression:- Delusion of Reference
41. Q. Tmhri mummy bta rahi thi k tumhe gussa bahut aata hai.?
A. Gussa aane ka wajah hai, meri maa hmesha dusre ki baatien sunti hai, dusre log se meri
baatien karengi, ab sab toa mere khilaf hi bolty hain, fir bhi un logo k saath hi baat karti hai,
main nhi chahata fir bhi gussa aa jat hai.
Q. Nhi chahta fir bhi gussa aa jata matlab ?
A. Matlab k main nhi chahata gussa krna , par aisa lgta k achank se gussa aa gaya, control nhi
pata aur jhgda ho jaata hai.
Q. Par gussa, jhgda toa tumhi karty ho, tmhi kuch soch kar gussa karty hoge na, khud se gussa
toa nhi aa skta na?
A. Main nhi sochta kuch, bas aa jata hai, nhi chahty hue bhi mera haath uth jaata hai.
42. ◦ Q. Toa fir tum haath nhi uthate, apne aap ho jaata ?
◦ A. Nhi main nhi uthata,mujhse karwaya jaata hai, taki main bura ho jau, aur sab mere khilaf ho
jaye, aur mujhy maar dale. Maine ye baat mummy aur behan ko bhi btai hai k main haath nhi
uthata, dusre log mujhse ye kaam karwaty hain, par meri mummy meri baat na maan kar, baki
logo se baat kar leti hai,aur sab bta deti,mil jaati .
◦ Q. Tum ye bol rahy k log tumse , tmhre marzi k virudh kaam krwaty?
◦ Haan, Mujhy hmehsa aisa hi lgta hai, k koi mujhse ye kaam krwta hai, mere virudh,aur main nhi
kabu kar pata, sab galat ho jaata,aur main bura ban jaata.
◦ Q. Par koi tmhe kaise control kar skta hai ?
◦ Mujhy nhi maloom , bas mera mann bilkul badal jaata hai. Jo main nhi krna chahta wo mujhse
karwa dete hain. Na chahaty hue bhi mujhy bura bna dete.
43. ◦ Q. Tmhy lgta hai koi aisa jariya hai, jisse log tmhe control kar skty hain ya tmhre marzi k khilaf
tumse kuch karwa skty?
◦ A. Haan jariya hai, log mujhy sound wave se mujhse sab kaam karwaty hain,mujhy control
hain, main nhi chahata fir bhi main jhgda kar leta, sab mummy aur behan k wajah se hota hai,
ink wajah se hi log mere vichar ko jaan jaaty hain aur fir badal bhi dete hain.
◦ Impression :- Delusion of Control
44. Q. Fir bhi tumhy ye possible lgta hai k koi kisi k vichar ko control kar k badal de, kabhi aisa suna
hai ?
A. Mujhy nhi pata ,par mere saath aisa hota hai, lgta hai k log mere log mujhy bura bnane k
mere soch ko badal dete. Kabhi kabhi toa aisa hota hai k jo main sochta wo sab ko pata chal
jaata hai.
Q. Ab ye kaise possible hoga k tmhre bina btaye sab ko tmhri baatein pata chal jaye?
A. Sab possible hai, jab koi kisi ko nuksan krna chahy toa kuch bhi ho skta hai.
Q. Aur ye sab kuch wo kaise karty hain ?
A. Sound wave se karty , isi wave se mera vichar travel krta hai aur sab ko khabar ho jaata hai k
mere mann mai kya chal rha, main kahan ja rha, tabhi toa main jahan jaata , sab aa jaty, dekh
hasty rahty.
Impression:- Thought Broadcasting
45. Q. Tum ye baar baar apni haath kyu saaf karty rahty ho ?
A. Mujhy darr lgta rhta hai k kahi koi bimari na ho jaye. Is liye dhota rhta hoon.
Q. Din bhar main kitni baar haath dho lete ho?
A. Yaad nhi hai
Q. Fir bhi andazan?
A.10-15 baar dho leta hoon
Q. Tab toa kafi pareshani hoti hogi ?
A. Pareshani kyu ?
Q. Din bhar ain itni baar haath dhone k vichar aaty hain, itna samay lgta hai toa parshan toa hoge
na?
A. Nhi aisa nhi hai, jab mann hota hai dho leta hoon, aur jab mann kiya nhi bhi dhota hoon.
46. Q. Kabhi koshis kiya hai , in vicharo ko rokne ka?
A.Haan , koshis kiya hai, rok bhi leta hoon.
Q. Koi pareshni bhi hoti hai, in vicharo ko rokne main?
A. Haan ghabrahat si hoti hai.
Q.Ye jo vichar aaty hain , wo tmhre apne vichar hoty hain ya ye bhi kisi aur k hoty hain?
A. Ye mere apne hoty hain.
Q. Accha , tum jo ye shaq karty ho apne mummy aur behan par, kahi ye bhi toa bas tmhre vichar toa
nhi, aisa toa nhi k kabhi kuch hua nhi ho, bas tmhy aisa lgta rhta ho, bas tmhre vichar ho?
A. Nhi , ye mera waham nhi hai, maine dekha hai mummy ko sab log se baat karty hue, sabse
baat karti hai, fir wo saare log mere bade main baat karty hain.mujhy nuksan pauchna chatay
Impression :- Obsession??
47. ◦ Q. Kabhi aisa bhi hua hai k tum akele baithe ho aur tumhy koi aisi awaaz aati ho jo shirf tmhy
sunai deti ho, baki kisi aur ko nhi?
◦ A. Haan awaaz to aati hai.
◦ Q. Kiski awaaz hoti hai?
◦ A. mujhy nhi maloom.
◦ Q. Awaaz aati hogi toa pata chalta hoga na, k kiski awaaz hai? Aadmi ki hai ye aurat ki ?
◦ A. Haan pata chalta hai, kabhi aadmi ki hoti hai aur kabhi aurat ki hoti hai.
◦ Q. In awaaz ko pechan paaty ho, mera matlab k jaani pehchani awwaz hai ya anjaan logo ki
awaaz hai ?
◦ Nhi pechanta , mujhy nhi maloom ki kiski awaaz hai.
48. ◦ Q. Ye jo awwazein aati hai, ye tmhy kano se sunai deti hai , ya bas tmhri mann k vichar hai?
◦ A. Nhi mann ki awaaz nhi, mere kano se awaaz aati hai.
◦ Q. Abhi jaise meri awaaz sun pa rahy ho bilkul wasi awaaz hai,isi trha saaf saaf aati hai?
◦ A. Haan isi trha aati hai.
◦ Q. In awaazo k aane ka koi khaas waqt hai, jaise ki bas raat ko aati ho, soty hue?
◦ A. Nhi, hmesha aati hai, pure din aati rhti hai, kabhi bhi aa jati hai.
◦ Q. Hmesha ek hi insaan ki awaaz hoti hai?
◦ A. Nhi , kabhi aadmi ki awaaz hoti hai, kabhi aurat ki.
49. ◦ Q. Ek baar main ek hin insaan ki awaaz aati hai, ya ek saath kai awwaz aati hai?
◦ A. Kabhi ek aati hai, aur kabhi do teen awaaz ek saath aati hai.
◦ Q. Kya baatien karti hai ye awwazein?
◦ A. Kabhi mere khilaf bolti hai, kabhi mere mann ki baatien karti hai.
◦ Q. Mann ki baatien matlab?
◦ A. Matlab k jo main chahta hoon wo bolti hai.
◦ Q. Ye awaazein hmesha directly tumse baatien karti hai ya kabhi aaps main bhi karti hain ?
◦ A. Aaps main bhi karti hai, mujhy maarne ka planning karti hai, mujhy bhala bura kahti hai.
◦ Impression:- Auditory Hallucination ( 2nd and 3rd person ) commanding type
50. HIGHER MENTAL FUNCTION
Orientation- Timing of the day : Shaam k 5-6 bj rahy hain
◦ Date: ye nhi pata
◦ Month: Nov
◦ Year: 2021
◦ Place: Ye kaun si jgha hai:-PGI hospital
Kaun sa sehar hai:- Rohtak
◦ Person: Aap k saath kaun hai? Mummy
◦ Main kaun hoon:- Doctor
◦ Impression: Oriented to time/place/person
51. ◦ Attention and concentration
Digit span test
FORWARD BACKWARD
1,6 1,6 3,8 8,3
2,5,8 2,5,8 4,9,6 6,9,4
1,4,7,2 1,4,7,2 4,1,7,9 9,7,1,4
5,1,7,9,2 5,1,7,2,9 7,2,5,8,1 1,3,5,7
7,2,9,6,1 7,2,9, 4,6 9,5,1,6,2 2,6,9,5,4
Patient was able to complete 4 digits forward and till 4 digits backward
Serial digit subtraction
◦ (100- 7)= 93,86,79,72,65,58,51……(able to complete within 120 sec)
◦ Impression: attention is arousable and sustained.
52. Memory :
◦ Immediate:
◦ Registeration : 3/3
• Recall: 3/3
◦ Recent: Aapne aaj subah kya khana khaya tha?
Doodh and daliya, verified from the informant (intact)
Confirmed by mother
Remote: correctly told about the date of birth, passing 10th and 12th
Impression- Intact immediate, recent and remote memory
53. ◦ Intelligence:
General fund of knowledge-
• PM of india - Modi
• Haryana k CM - Khattar
◦ 3 akhbar ke naam – Hindustan, Panjab keshri, dainik bhaskar
◦ 3 nadiyo ke naam – ganga , Yamuna, saraswati
◦ Suraj kahan se nikalta hai - purav
◦ Bharat ke jhande me rang – santri, hara ,safed
◦ Haryana ki rajdhani - chandigarh
◦ Mirror Kitne type k hoty hain:- concave, convex, plane
◦ (A+B)2 = a2+b2+2ab
◦ Score-10/10
IMPRESSION – adequate general fund of knowledge
54. Similarity:
Q pakshi and aeroplane
A dono ud sakty hai 2
Q pen and pencil
A dono likhne k kaam aaty hain 2
QOrange and apple
A khane ka saman hai 1
Q table and chair
A dono lakdi ka hai 1
Q bus and car
A dono sawari hai 2
Score – 8/10
55. Proverbs :
Q. 9 2 11 hona
A .Bhaag jana
Q. Haath peele karna
A. shadi karna
Q. Pet me chue kudna
A. Bhookh lagna
Q. Swarg sidharna
A. Mar jana
Q. Akal la dushman.
A. Nhi pata
Score – 10/10
IMPRESSION – thinking is abstract
56. ◦ Judgement:
Personal-
Q –aap yaha se wapas jakar kya karenge?
A. – Kaun sa ghar mera koi ghar nhi
Q. Jahan aap rahty ho, wahan ja kar kya karoge
A. Kuch nhi krunga
B. Chutti milne k baad kuch plan hai k aage kya krna hai?
A. Mujy yahan se kahi nhi jana , bahar mujhy hatra hai
Social- Impaired
Test- Fire problem- agar yaha kamre ke kone me aag lag jaye to aap kya karenge?
A. Main kya karunga, jo mere mann mai aayega wo karunga, mummy aag lagai hogi,aur main kyu kuch
jisne lgya hai wo karega.
Letter problem- agar aapko sadak pe jate hue ek letter mile jisme naam pata likha ho, aap us letter ka kya
karenge?
A. Mujhy nhi pata kya karna hai, mujhy kuch nhi karna hai.
Impression:- Impaired personal, social and test judgment
57. Insight :
Q- Apko lagta hai ki kisi tarah ki takleef hai?
A. Haan
Q. Apko lgta hai k aapko mansik dikkat hai?
A. Haan , darr lgta hai , par insab ka karan ye log hain jo mere bare baat karty hain aur jo mujhy
maarna chahty hain, ink wajah se hi mera dimag kharab hua hai
◦ Insight- 3/5
58. DIAGNOSTIC FORMULATION
Mr A, 18 years old , unmarried male , 12th pass, student, belonging to a Hindu nuclear family of lower socio-
economic status of rural background of Mahendargarh, presented with episodic illness of total duration of 2
years with current episode of duration of about 3 months, with acute onset of symptoms characterized by
irritable and aggressive behaviour ,decreased sleep, fearfulness, suspiciousness and refusal to take food and
medicine with h/o one episode about 2 years back characterized by suspiciousness, decreased sleep and ,
with complete inter episodic recovery , poor compliance on treatment, with family history of psychiatric
illness in father with well adjusted PMP, with no abnormality on GPE& and systemic examination. On MSE,
General appearance and behaviour – Patient was constantly suspicious during the interview and kept asking
questions like what the interviewer writing down in the page, patient was also doubtful that interviewer was
recording the whole conversation and insisting to show mobile phones ,eye to eye contact – made and
maintained, rapport – established, Psychomotor activity and reaction time normal, normal speech, Mood and
Affect ,(S) – Darr lag rha h,(O) – Irritable, thought content- delusion of persecution, delusion of control;
thought possession: Thought broadcasting, Perception- 2nd /3rd person auditory hallucination. With HMF-
WNL, Impaired Personal, Social and Test judgement, insight 3/5.
59. ◦ Based on general physical examination including systemic examination and detailed
history, and mental status examination, organic cause is ruled out
60. PROVISIONAL DIAGNOSIS
◦ ICD-10 code- F20.01 : Paranoid Schizophrenia
POINTS IN FAVOUR
Thought broadcasting ( Criteria a)
Delusion of control ( Criteria b)
Hallucinatory voices giving command to patient and discussing the patient among themselves
Delusion of persecution
Symptoms present for duration of more than one month
Age of onset
Positive family history
61. DIFFERENTIAL DIAGNOSIS
◦ ICD-10 code- F22.0 : Persistent delusional disorder
POINTS FOR
Presence of prominent paranoid delusions
POINTS AGAINST
General criteria for diagnosis of schizophrenia is satisfied
Presence of prominent hallucinations
62. DIFFERENTIAL DIAGNOSIS
◦ Schizophrenia with obsessive compulsive symptoms
POINTS FOR
General criteria for diagnosis of schizophrenia is satisfied
POINTS AGAINST
General criteria for diagnosis of OCD in not satisfying
Thought is under control by patient
No egodystonic
No Stress
64. Ward progress
DATE TREATMENT PROGRESS/WARD
12.11.21 T. Olanzapine 10 mg 1H.S.
T. Clonazepam 0.5 mg ½-x-1
PANSS: P=28 G=38
N=14. C=14
17.11.21 Same Improvement in sleep, appetite
23.11.21 T.Olanzapine 12.5mg 1H.S
T. Clonazepam 0.5mg ½-x-1
PANSS P=28 G=38
N=14. C=14
65. MANAGEMENT ISSUES
◦ Issues identified :
◦ Acute
◦ Management of acute symptoms
◦ Denial for food and medications
◦ Long Term
◦ Adherence to treatment
◦ Management of residual symptoms
◦ Long acting injectable
66. MANAGEMENT PLAN
• Investigations: serum electrolytes, KFT, LFT, FBS, Lipid profile,
Complete hemogram
• Inpatient admission
• Vitals monitoring
• Input/ output charting
• Pharmacological
• Non – pharmacological
• Rating Scale for monitoring : PANSS score
• Review treatment plan accordingly as per progress of patient
69. PANNS Scores
◦ Total positive score-28
◦ Total negative score-14
◦ Total general score- 38
◦ Composite score-14
◦ IMPRESSION- Predominant positive
70. Long Term Management
◦ Psychoeducation regarding illness to family members and patient
◦ Psychoeducation regarding adherence to treatment to family members
and patient
• Activity scheduling of the patient
• Engagement of the patient in Yoga.
71. FURTHER MANAGEMENT
• To attain remission and to continue the pharmacotherapy in the same effective dose
in which patient gets stabilized.
◦ Focus will be on improving level of functioning and prevention of recurrence.
◦ Advise for regular follow ups to monitor the response, side effects and treatment
adherence.
74. ◦
FAMILY TREE
Died at the age of 75
In 2016
75 years old house wife uneducated
40 years
old
Uneducate
d
Married
12th passed , 38 years old married
Work in army
40 years old,10thpassed, house wife
45years
Old 8th
Pass, farmer
15 yeas old, studying in 9th class
20 years old ,
Studying in
BA 1st
75. ◦ Good interaction pattern among siblings
◦ Good interaction pattern with patient and others family members at present
Impression: Direct and healthy interaction pattern
INERACTION PATTERN
76. ◦ Patient belongs to Hindu Nuclear family of lower socioeconomic status
residing in rural background of district Mahendargarh.
He is currently living with his family
( *As per modified Kuppuswamy Socio-Economic Status Scale )
FAMILY DETAILS
77. ◦ Having concrete house of their own.
◦ All the basic facilities are available in the house.
◦ Adequate water & electricity supply is present.
PRESENT LIVING CONDITIONS
78. ◦ Symptoms of psychiatric illness is present in his father.
◦ No history of any substance use in his family.
◦ No history of suicide in his family.
◦ No history of abscond in the family.
FAMILY HISTORY
79. ◦ Family is following Hindu religion.
◦ All family members have religious faith and belief.
◦ Patient occasionally used to visit temple before onset of his illness.
FAMILY VALUES AND BELIEFS
80. ◦ Family members considers it to be a psychiatric illness that can be treated by a
psychiatrist.
FAMILY KNOWLEDGE AND ATTITUDE TOWARDS
PATIENT’S ILLNESS
81. Role and functioning: -
◦ Role is poorly defined and all major roles performing by pts mother with the
help of other family members but patient and his father is unable to perform
their role due to their illness.
Boundaries :-
◦ Family matters are resolved democratically and internally. Also, advice from
relatives is taken wherever necessary. Hence, Boundaries are semi- permeable.
FAMILY DYNAMICS
82. Leadership & Decision making:-
◦ His mother is nominal and functional head of the family. Leadership is
accepted by all family members.
◦ All the decision are taken with mutual consent of all the family members.
Communication:-
◦ Direct and Clear communication pattern is present in the family. Every
member of the family openly communicate with each other about their needs.
FAMILY DYNAMICS
83. Cohesiveness:-
◦ “We feeling” is present in the family. Family members involve the patient in
every social gathering and ensure his participation.
Family adaptive pattern:-
◦ Mutual understanding and trust is present in the family which leads to effective
crisis management.
FAMILY DYNAMICS
84. ◦ Primary support:-
Patient is getting appraisal, informational and instrumental support
from the family members .
◦ Secondary support:-
Patient is getting adequate support from relatives & neighbors
◦ Tertiary support:-
Institutional support is available & accessible by the patient.
Impression:- Primary, secondary and tertiary
Support is adequate
SOCIAL SUPPORT
85. ◦ Mother is the only active functioning member in the family and 2 sister are
persuading their studies. Pt and his father both are unable to contribute in the
household work and many times they need assistance.
◦ Indicating high level of caregiver burden.
◦ There is no structured source of income and apart from pts treatment household
liabilities are bit high that imposes financial burden in the family.
FAMILY BURDEN
86. ◦ Both the male member of the family are currently unable to
perform as per as per social expectations and pt’s mother have
to manage all the responsibilities that many times became
difficult for her.
◦ The condition indicating of high social burden and impact on
other
87. FAMILY BURDEN INTERVIEW SCHEDULE
Impression – Moderate effect on , Financial Burden, Disruption Of Routine
Family Activities, Disruption Of Family Leisure, Effect On Mental Health of Other
88. ◦ Pt is symptomatic since July 2021, and stopped taking
medication by his own, mother used to blame him for the same
and at a time she slap him and start scold him for his behavior.
◦ That indicates inappropriate attitude of a mother goes in the
favor of Hostility .
◦ Another hand she consider that he is the only male child and she
would do anything for his care
89. ◦ She admit that she would do anything for his care and wellbeing.
◦ Conditions shows high emotional over involvement.
91. ◦ Patient Mr. A, 18 years old, completed 12th standard unmarried,
belonging to a Hindu nuclear family of lower socioeconomic
status from rural background of district Mahendragarh,
Haryana.
◦ Psychosocial assessment shows:- Poor medication compliance,
poor knowledge regarding illness, family burden, high
expressed emotion of family members towards patient.
PSYCHOSOCIAL FORMULATION
92. ◦ Z91.1- Personal history of noncompliance with medical
treatment and regimen.
◦ Z81.8- Family history of other mental and behavioural
disorders.
PSYCHOSOCIAL DIAGNOSIS
(ICD-10)
93. ◦ Poor knowledge about illness.
◦ Poor compliance.
◦ Poor role performance.
◦ Family burden.
(Financial Burden, Disruption Of Routine Family Activities, Disruption of Family Leisure, Effect
On Mental Health of Other)
◦ High expressed emotion.
(Hostility and dissatisfaction)
PSYCHOSOCIAL MANAGEMENT ISSUES
94. ◦ Psycho education of the family members.
◦ Nature and course of illness.
◦ Importance of treatment and adherence.
◦ Medication compliance.
◦ Supportive psychotherapy for mother.
◦ Activity Scheduling of the patient.
◦ Social security scheme (Unemployment).
PSYCHOSOCIAL MANAGEMENT PLAN
95. Sessions Details
A total of four session have been conducted with patients and her
family members.
PSYCHOSOCIAL MANAGEMENT
SESSIONS
Session No intervention
1 Intake session ( Patient
his mother
2 Family assessment
3 Psycho education
4 Supportive
psychotherapy
96. Session No I
Date 14/11/21
Duration of session 50 Minutes
Session participant Pt. And His mother
Key issues/ Themes discussed Rapport Establishment
Understanding the family
perception of the patient's
problem.
Method used Interviewing
Therapist observation and
reflection
Pt. mother explained about the
symptoms, and their problems, she
is very sad during the session .but
pt is not cooperative , he was
irritate and aggressive.
Plan Assessment of family dynamic
.
97. Session No II
Date 16/11/21
Duration of session 45 Minutes
Session participant Pt,s Mother, therapist and co
therapist
Key issues/ Themes discussed Family Dynamic Assessment
Assessment of family burden and
expressed Emotion
Method used Interviewing and questionnaires
Therapist observation and
reflection
There is poor knowledge about illness
in mother, family burden, high
expressed emotion of family members
towards patient.
Plan Psycho education
.
98. Session No III
Date 19/11/21
Duration of session 30 Minutes
Session participant Pt’s mother, therapist and co
therapist
Key issues/ Themes discussed Awareness of illness ,Importance
of treatment, Medication
compliance.
Method used Psycho education
Therapist observation and
reflection
Pt’s mother was able to understand
the basic concept of
hospitalization (need, limitations
and strength) importance of
treatment and adherence.
Plan continue psycho educations
sessions and start Supportive
psychotherapy with mother
.
99. Session No IV
Date 23/11/21
Duration of session 40 Minutes
Session participant Pt’s mother and sister, therapist
and co therapist
Key issues/ Themes discussed Assurance, problem solving
suggestion
Method used Supportive psychotherapy
Therapist observation and
reflection
Pts mother and his sister feel better
although they try to understand
about the problem solving
suggestions like how to behave
with patient also they share their
experiences to live with patient.
100. ◦ Continue Family Psycho education.
◦ Continue Supportive session for mother.
◦ Activity Scheduling of the patient.
◦ Social security benefits for the patient.
◦ Monitor follow up session /visit
◦ Bringing father in the treatment.
FUTURE PLAN
