This document provides information about a patient's history and treatment plan. It summarizes that the patient is a 25-year-old male who has been experiencing sexual attraction towards children for 9 years, concerns about penis size for 8 years, low mood for 8 years, and headaches for 2 years. He has been treated by multiple doctors with various medications without significant improvement in his symptoms. The diagnosis is hypochondriacal disorder, pedophilia, dysthymia, depressive episode, tension headaches and probable migraines. The treatment plan is to continue SSRI medication and topiramate, and add cognitive behavioral therapy and psychoeducation for the patient and his family.

1. WISH YOU ALL
HAPPY AND PROSPEROUS
NEWYEAR-2010

2. AIM OF PRESENTATION
Formulation of Management Plan

3. Source of InformationSource of Information
 Informants – Patient,Informants – Patient,
Patient’s father &Patient’s father &
Patient’s cousinPatient’s cousin
CRF, Old prescriptionsCRF, Old prescriptions
investigation reportsinvestigation reports
 Information is reliable & adequateInformation is reliable & adequate

4. PRESENTING COMPLAINTS
Sexual attraction towards children – 9 yrs
Concerns having small penis – 8-9 yrs
Low mood, interest in activities – 8 yrs
Headache – 8 yrs ( 2 yrs)
Decreased energy Remaining alone
Death wishes
6-7 months

5. HISTORY OF PRESENT ILLNESS
• Onset - Insidious
• Course - continuous
• Progress - Deteriorating

7. TREATMENT HISTORY
DateDate DrugsDrugs DurationDuration ComplianceCompliance ResponseResponse SideSide
effecteffect
Dec 2007-Dec 2007-
DermatologiDermatologi
st,st,
AzamgarhAzamgarh
REASSURANCEREASSURANCE
T. Duloxetine 40mgT. Duloxetine 40mg BDBD
T. Alprazolam 0.25mgT. Alprazolam 0.25mg
+ propranolol 20mg+ propranolol 20mg
Cap. MultivitaminsCap. Multivitamins
? T.Camifto BD? T.Camifto BD
4 month4 month GoodGood GoodGood
(attributes(attributes
toto
reassuran-reassuran-
ce)ce)
NoNo
Oct -Nov 08Oct -Nov 08
AllahabadAllahabad
govt.hospitalgovt.hospital
T. B complexT. B complex
T. ClonazepamT. Clonazepam
0.25mg HS0.25mg HS
20 days20 days GoodGood NoNo NoNo
Dec 2008Dec 2008 T. Escitalopram 10T. Escitalopram 10
mgmg
T.Lorazepam 1 mgT.Lorazepam 1 mg
15 days15 days GoodGood NoNo NoNo

8. TREATMENT HISTORY Cont……..
Date Drugs Duration Compliance Response Side
effects
Dec 2008
Dermatologist,
Azamgarh
T .Fluoxetine 20mg BD
T.Alprazolam0.25mg+
T.Propranolol20mg
1 month Good No No
Feb. 2009
Physician
Azamgarh
T. Sertraline 50 mg HS
T. Ergotamine 1mg
+ Caffeine 100mg +
Belladona 10mg +
Paracetamol 250 mg SOS
T.Flunarazine 10 mg HS
T. Clonazepam 0.25mg HS
2 month Good Decreased
frequency
of
headache
No
May 2009 T. Propranolol HS
T.Sertraline 50mg OD
T. Clonazepam 1mg HS
1month Good No No

9. TREATMENT HISTORY Cont……..
DateDate DrugsDrugs DurationDuration ComplianceCompliance ResponseResponse SideSide
effecteffect
Sep. 2009,Sep. 2009,
Physician,Physician,
AzamgarhAzamgarh
T. Divalproate 500-T. Divalproate 500-
800mg OD800mg OD
T. Sertraline 50 mg HS
T. Meloxicam BD
Cap. Multivitamins
15 days15 days GoodGood NoNo NoNo
Oct. 2009,Oct. 2009,
Pvt.Pvt.
Psychiatrist,Psychiatrist,
AzamgarhAzamgarh
? T. Reximine? T. Reximine
TDSTDS
T.Hydroxyzine HST.Hydroxyzine HS
Cap.Cap. MMultivitamins
1 month1 month GoodGood NoNo NoNo
Nov. 2009,Nov. 2009,
Pvt.Pvt.
Psychiatrist,Psychiatrist,
AzamgarhAzamgarh
T. EscitalopramT. Escitalopram 55
mg/ daymg/ day
T. OlanzapineT. Olanzapine 2.5 mg2.5 mg
HSHS
T. AlprazolamT. Alprazolam 0.5mg0.5mg
BDBD
1 month1 month GoodGood NoNo NoNo

10. TREATMENT HISTORY Cont……..
DateDate DrugsDrugs DurationDuration ComplianceCompliance ResponseResponse SideSide
effecteffect
1919
Dec.2009Dec.2009
CIPCIP
Cap. Fluoxetine ,
hiking upto
40mg/day
T.Clonazepam
0.5mg (tapering dose)
T.Topiramate
50mg/day
T.Metoclopromide
5mg + Paracetamol
500mg prn.
13 days13 days GoodGood -- NoNo

11. PAST HISTORY -Nil contributory
FAMILY HISTORY
• Born out of non consanguineous marriage. No contributory history
PERSONAL HISTORY
• FTNVD at home, no antenatal, natal or post natal complication.
• Normal developmental milestone.
• Congenial home atmosphere.
• Completed BSc in 2004.
• Worked with brother as insurance agent for 2 years.
• Currently studying BEd .
FORENSIC HISTORY
• Nil reported
PREMORBID TEMPERAMENT-Well adjusted

12. PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
General Appearance-General Appearance-
Average body built .weight-67kgsAverage body built .weight-67kgs
pallor, cyanosis, clubbingpallor, cyanosis, clubbing -- NilNil
Icterus, oedema, neck veinIcterus, oedema, neck vein
No thyromegalyNo thyromegaly
Cardiovascular systemCardiovascular system
Pulse- 88/min, regular, good volume, no radio-radial andPulse- 88/min, regular, good volume, no radio-radial and
no radio-femoral delayno radio-femoral delay
B.P-126/84 mm of Hg, right brachial, supineB.P-126/84 mm of Hg, right brachial, supine
11stst
&2&2ndnd
heart sounds audibleheart sounds audible
no murmur.no murmur.

13. RESPIRATORY SYSTEMRESPIRATORY SYSTEM
Respiratory rate 19/min, abdomino thoracicRespiratory rate 19/min, abdomino thoracic
Trachea central normal symmetrical movementTrachea central normal symmetrical movement
B/l chest clear, no adventitious soundsB/l chest clear, no adventitious sounds
AbdomenAbdomen
Flat no distention.Flat no distention.
soft , nontender, no organomegalysoft , nontender, no organomegaly
BSBS ++
GenitalsGenitals
Penis flaccid state-5.5cm.(7-11cm)Penis flaccid state-5.5cm.(7-11cm)
Erect state-11.5cm(14-17cm)Erect state-11.5cm(14-17cm)
Scrotum-normal testisScrotum-normal testis

14. Central nervous systemCentral nervous system
Patient conscious, comprehension normal.Patient conscious, comprehension normal.
Speech and language normalSpeech and language normal
Cranial nerve examination within normal limitsCranial nerve examination within normal limits
Motor system & reflexes within normal limit.Motor system & reflexes within normal limit.
Sensory system intact.Sensory system intact.
Cortical functions intactCortical functions intact
Autonomic system within normal limitAutonomic system within normal limit
No signs of meningeal irritationNo signs of meningeal irritation
Cerebellar signs not presentCerebellar signs not present
Gait, spine within normal limitsGait, spine within normal limits

15. INVESTIGATIONSINVESTIGATIONS
Outside hospitalOutside hospital
Semen analysis-NormalSemen analysis-Normal
HIV1 &2 -NegativeHIV1 &2 -Negative

16. MENTAL STATUS EXAMINATIONMENTAL STATUS EXAMINATION
 Kempt, tidy, in touch with the surrounding, lookingKempt, tidy, in touch with the surrounding, looking
good and appropriate to his age, average body built,good and appropriate to his age, average body built,
adequately dress, down gazing, poorly making eyeadequately dress, down gazing, poorly making eye
contactcontact
 Cooperative attitude, rapport established.Cooperative attitude, rapport established.
 Normal and appropriate motor behaviorNormal and appropriate motor behavior
 Speech- soft tone , intensity, normal reaction time,Speech- soft tone , intensity, normal reaction time,
relevant, coherent, goal directed, normal productivityrelevant, coherent, goal directed, normal productivity

17.  Cognitive functions- within normal limits.Cognitive functions- within normal limits.
 Affect-depressed,Affect-depressed,
restricted range & normal reactivityrestricted range & normal reactivity
communicable appropriatecommunicable appropriate
 Thought : stream-no abnormalityThought : stream-no abnormality
form - no abnormalityform - no abnormality
Possession -no abnormalityPossession -no abnormality

18.  Thought content: Somatic concernsThought content: Somatic concerns
ideas of hopelessnessideas of hopelessness
ideas of helplessnessideas of helplessness
deathdeath wisheswishes
 Perception: No abnormality elicitedPerception: No abnormality elicited
 Judgment : impaired personalJudgment : impaired personal
 insight :grade IVinsight :grade IV

19. Course in hospital

20. DIAGNOSTIC FORMULATION
Index patient Mr. M.K.Y 25 yrs U/H/M, MSES rural background of
U.P, nil contributory past history, nil contributory family history well
adjusted premorbid temperament comes with history of feeling
attracted towards children 9 years with 3 incidents of sexual act with a
prepubertal child with history of concern about having small thin penis
for 8 years with low mood, lack of interest in activities for 8 years with
headache from 8 years increased from last 2 years with remaining to
self, decreased energy death wishes 5-7 months with GPE-WNL with
Mental Status Examination- Kempt tidy, co-operative with soft speech,
normal cognition. Depressed affect restricted range with somatic
concern, ideas of hopelessness, helplessness & death wishes with
impaired personal judgment and grade IV insight.

21. DIAGNOSIS
ICD-10: Hypochondriacal disorder(F- 45.2)
Paedophilia(F-65.4)
Dysthymia(F-34.1)
Moderate depressive episode with somatic
symptoms(F-32,11)
Tension type of headache(G44.2)
Probable Migraine without aura(G-43.83)

22. DSM-IV-TR
Axis I :300.7 Body dysmorphic disorder
302.2 Pedophilia, Sexually attracted to both,
Non exclusive type
300.4 Dysthymia
296.22Major depressive Disorder, single episode, moderate
Axis II :No Diagnosis
Axis III :Tension type headache
Probable Migraine without aura
Axis IV : No Diagnosis
Axis V : GAF-40(current)

23. PLAN OF MANAGEMENTPLAN OF MANAGEMENT
 PharmacologicalPharmacological :-:-
1.1. SSRI to be continued as treatment of choice as it is helpful inSSRI to be continued as treatment of choice as it is helpful in
BDD, Pedophilia and DepressionBDD, Pedophilia and Depression
2.2. Topiramate to continue as prophylaxis of migraine headacheTopiramate to continue as prophylaxis of migraine headache
 NonpharmacologicalNonpharmacological :-:-
1.1. Cognitive behaviour therapy is found to be effective .Cognitive behaviour therapy is found to be effective .
2.2. Psychoeducation to patient & his family.Psychoeducation to patient & his family.

24. DISCUSSIONDISCUSSION

25. Thank you…Thank you…
2009
Thank You