The document presents a detailed clinical case of an 18-year-old female patient named Miss RK, who has been consuming non-nutritive substances (soil, brick, and ash) for 15 years, with symptoms of low mood, headaches, and restlessness accompanied by significant psychological distress stemming from a traumatic event. Her family history includes a positive psychiatric background, and after multiple visits to the clinic, she was prescribed medication which initially resulted in improvement, though her condition deteriorated again leading to hospitalization. The patient's journey reflects complex psychiatric issues compounded by trauma and family dynamics, underscoring the need for comprehensive mental health care.

1. Case presentation
Presenter
Dikendra Sanjyal
Department of psychiatry
NMCTH,Birgunj
2081/05/25

2. Patient particulars
 Name: Miss RK
 Age: 18 years
 Sex: Female
 Religion: Muslim
 Education: Studying in class 12
 Occupation: Currently unemployed
 Marital status: Unmarried
 Socioeconomic Status: Lower middle class
 Family type: Nuclear
 Address: Birgunj
 DOA- 1st
Aug 2024
 DOE-1st
Aug 2024

3.  Source of referral: Family members
 Source of information:
 Patient herself
 Mother: Mrs. U.K, 40 year, married, Secondary level, Homemaker by
occupation, has stayed with the patient during entire period of illness
 Information provided is reliable and adequate

4. Chief complaints
 According to the patient:
 Consumption of soil, brick for 15 years
 Headache for 6 year
 Low mood for 6 years
 According to informant:
 Persistent eating brick,soil,Ashes for 15 years
 Headache for 6 years
 Restlessness for 6 years
 Low mood for 6 years

5.  Total duration of illness: 15 years
 Onset was insidious
 Course was continuous
 Predisposing factors: Positive family history of psychiatry illness in her father
and elder siblings
 Precipitating factors: Psychological trauma
 Perpetuating factors: could not elicited

6. History of presenting illness:
 According to the informant, she was apparently well 15 years back. One day
the informant noticed that the patient was eating soil and other non-food
substances while playing in the ground. She didn't pay any attention at the
time. The informant thought that she was too small to distinguish between
edible and non-edible food.

7.  The days went by, and when she was about 10-12 years old, the informant
found her maximum time with eating soil,clay,brick and ash . By this time, she
would be able to do household chores; she was reading in class six in a private
school and did well in her studies. She would go to the market to make small
and large purchases and had knowledge of distinguish the things which are
for eating and not eating.

8.  The informant used to allegedly beat her by telling her not to eat bricks, soil,
and ashes whenever she used to find her during eating this substances. But
the patient didn't listen to her, and whenever she saw the earth, brick, and
ash, she had a strong crave to eat that kind of substance. She said that it was
difficult for her to control eating because she felt restless, characterised by a
rapid heartbeat which persisted for some time and only relieved after eating
that non nutritive things.
 She had knowledge of eating this substance can causes harmful health
problems but she never left to eat such substances.

9.  Due to eating non nutritive substances behaviour, she had to visit clinic due to
sudden onset of pain in the upper quadrant of the abdomen, diffuse in
nature, lasting from several hours to a day, occurring at intervals of 2-3 days.
This pain was relieved by taking medication, and she had difficulty
functioning.

10.  How often did the informant scold her for not eating such a substance? When
asked, the patient replied, "She had a sudden urge to eat such a substance and
had difficulty controlling this urge. It was continuous in nature but whenever
she had stressor related to academic at that time she used eat more than usual
day.
 Despite the regular consumption of non-nutritive substances, the patient had
regular appetite, sleep, and bowel and bladder control

11.  Six years ago, there was a pandemic of the Corona virus and there was a
lockdown. At that time, the grandfather of the patient had a sudden onset of a
fever. The fever was unrecorded at the time. It was accompanied by a dry
cough and difficulty breathing. The family members then suspected that he
was suffering from Corona. They took him to NMCTH, where he was
admitted.

12.  For the treatment of the grandfather, all the family members were present in
the hospital. The patient was alone in the house. At that time, one of the
recognised neighbours suddenly came into her house and tried to physically
assault her. He threatened her not to tell others and that he would tell
everyone in the village. The patient couldn't control herself. She cried for a
long time in the house. In the evening, her family members returned home
and saw her face as sad. She did not communicate well with other family
members. When they asked the patient what the reason was, she didn't
answer and was in tears for some time. Then the family members didn't
bother her. They thought it was part of her grandfather's illness.

13.  The patient didn't tell anyone about the event and spent time alone in
the room. She didn't communicate with other family members, as she
used to communicate well with other family members. Most of the time
was spent thinking about what happened. She didn't have sleep at night
and had difficulty with sleep onset. She would keep thinking about the
event, which would often make her want to roll and toll over bed. At 12-
1am, the patient would fall asleep and wake up at a regular time in the
morning.

14.  The patient didn't respond immediately when called by friends and teachers
in the school, and they had to call several times to respond, and previously the
patient would respond in one call and used to share small things with friends
and spend time with friends and family members.

15.  When others saw this kind of behaviour from the patient, they would try to
console her, but she wouldn't respond and would go out of the house. The
patient used to get anxious thinking that this event would happen again and
would be restless.
 She would have repeated flashbacks of this event day and night. While
sleeping, the patient saw the dream and woke up between sleeps, leading to
disturbed sleep.
 In school, she had flashbacks of events and got anxious. While having a
flashback of the event, she didn't interact with others. The flashback was
persistent and continuous.

16.  While walking in the street and at school, the patient used to get anxious by
thinking about the events and didn't communicate with others at that time.
 After 2 years of the event, the patient shared all the things with her mother
and started to cry in front of her. During this period, the patient was able to
talk to her mother about the event and had difficulty forgetting it. She had
also thought that life would be better after death, but she never tried it.

17.  Day by day, the patient's performance at school deteriorated as she had
difficulty concentrating on her studies due to a disturbing flashback. This
flashback was clear as water, vivid, and occurred at any time and leads to
crying and sometime tearful eyes. She failed in class 10. Previously, the patient
had studied regularly and was an average student who had never failed an
exam.

18.  With these symptoms, the patient visited the NMCTH and was prescribed a
capsule of fluoxetine 20 mg per day and a tablet of olanzapine 5 mg per night.
She improved by 70-80% with regular medication for 4 months, after which
she stopped the medication.

19.  A few days later, the patient had a sudden onset of headache involving one
side of the head, throbbing in nature, lasting 1-2 hours, radiating to the other
side of the head, associated with dizziness and tearing from both eyes, and
difficulty seeing the near object, which usually occurred while she was having
a flashback of an event. After consultation with a respected department, she
used glasses and improved.

20.  She became irritable with members of her family, and this irritability usually
came on when someone was trying to ask her a question.
 As a result of this flashback, the patient began to check the door repeatedly at
night, and when asked, the patient replied, "If I don't lock the room, the
neighbour will come in the absence of family members, and this event will
happen again.

21.  She thought that all men of this gender would do this to her, so she didn't
communicate with her male friend after that.
 She started taking her medication irregularly again for 1 year. Her headaches
made it difficult for her to fall asleep. She would eat non-edible substances
until now and was admitted to the psychiatric ward for better management.

22. Negative history
 No h/o headache, fever, vomiting, head trauma
 No h/o use of any psychoactive substances
 No h/o overfamiliarity, talkativeness, distractibility, hyper religious behavior
 No h/o chest pain, difficulty in breathing, palpitations, feeling of impending doom
 No h/o distressing thoughts or repetitive actions
 No h/o seeing things which is not seen by others and hearing of voice which is not
heard by others.
 No history of someone had taken his thoughts from his brain or someone had inserted
thoughts in the brain.

23. Treatment history
 Mention in HOPI.

24. Past history
 No h/o hypertension, diabetes mellitus, pulmonary tuberculosis or thyroid
disorder
 No h/o any surgical illness or procedures
 No h/o any other psychiatric disorders
 Difficult in seeing near vision for 2 years and under treatment.

25.  Family History:
+VE PSYCHIATRY
ILLNESS IN
FATHER
Mother
Grandfather
died due to
aging at 70
years
Grandmother
died due to
aging at 67
years
+VE
PSYCHIATRY
ILLNESS

26.  Patient’s belonged to nuclear, Lower middle socioeconomic status of Muslim.
Her family consisted of father, mother and 5 children including her.
 Siblings:
 Eldest sister: Miss YJ. Ansari 25 year old, studying in Bachelor level has
symptoms of suggestive of schizophrenia, no medical and surgical illness and
has staying with patient.
 Eldest brother : Mr SA. Ansari 22 year old, educated up to 8th
class,
worked as mechanic in garage, has been staying with patient and
primary breadwinner of the family.

27.  Youngest brother: Miss SJ. Ansari 15 year old, studying in class
9,unemployed, has been staying with patient and know about her
illness.
 Patients father: Mr SJ. Ansari, 53 years old married Muslim, Labour by
occupation, educated up to primary level, has symptoms suggestive of
schizophrenia under medication for 2 years and Head of the family and
primary breadwinner.
 Patient mother: was primary care giver.

28.  IPR among family members-good except with her father due to illness.
 IPR between family members and patient –good
 Family members support her fully both emotionally and financially
 No history of continuous stressor in the family
 No history of medical/surgical illness in the family

29.  PRESENT LIVING SITUATION
 Own pucca house
 No overcrowding
 Well and adequate ventilation with proper sanitation

30. PERSONAL HISTORY
 Birth history
 Ante-natal History
 Planned and wanted pregnancy
 No h/o Medical illness (Diabetes/ HTN Jaundice /STD)
 No h/o hyper-emesis, 1st
trimester X-ray exposure, drug intake (other than folate, iron,
calcium) or psychotropic, alcohol or tobacco use
 Irregular ante-natal visits and immunized with 2 doses of TT
 USG was done and no abnormality found
 No h/o complications such as Rh incompatibility, twin pregnancy, threatened abortion ,
Bleeding, Pre-eclampsia, Eclampsia
 Fetal movements were perceived throughout the pregnancy (not excessive or sluggish)

31.  Natal history
 Born at the home via NVD at term.
 Presentation:? longitudinal, cephalic
 No h/o large head, low placenta, prolapsed cord, cord around neck, fetal
distress, prolonged labor, PROM, non-progress of labor, or meconium stained
liquor, excessive bleeding

32.  Neonatal and post-natal History
 Birth weight could not be remembered , cried immediately after birth, color : Pink
 No h/o Respiratory distress
 Activity Normal, Suckling Normal
 Feeding : Breast fed exclusively for initial 6 months : on demand
 No feeding problem
 No abnormalities in Urine/ stools
 No congenital anomalies/ stigmata noticed
 No h/o Neonatal seizures, Jaundice, Infection, Hospital stay
 Immunized according to Immunization program of Nepal, documents not available

33.  Developmental history:
 Informant didn’t know exact time of milestones achieved but said there
was no developmental delay and achieved all the milestones as
compared to other siblings.

34. Childhood and adolescent history
 She used to spend most of his time playing with her friends.
 Had no difficulty getting involved with new people.
 Used to get angry often with friends while playing but did not use to get involved in physical fights.
 No h/o serious childhood illness requiring medical attention.
 No h/o behaviors such as nail biting, temper tantrums, or bed wetting.
 No h/o Bruxism/ sleep walking/ limb movements, Nightmares and night terror.

35.  Play
 Preferred group play with her siblings and cousins, she mixed well with other
children from her class
 No indifference towards playmates or siblings
 No h/o inappropriate intrusion or impulsivity during play
 Understood games governed by rules
 Showed co-operation during play
 Did not bully other children
 Did no get bullied by other children

36.  Education
 Type of schooling: day-government School
 Nature of school: Normal
 Any literacy exposure before formal schooling? No.
 Started schooling at approximately 4-5 years
 Class 1-8: in her village private school
 Class 9-12: in her village in government school, changed school due to financial problem
 Average in study
 After that event the performance in higher class was decreased and fail in one subject in class 10.
 No history of disciplinary action in school
 Attendance: Regular
 Peer group adjustment: average
 Problems with teachers: Nil
 Class room behavior: Favorable, no altercations with peers or teachers

37.  Occupational history: currently unemployed
 Menstrual history:
 Menarche : 12 years
 Regular cycles, 30 +/- 3 days
 Flow: 4-5 days, uses 3-4 pads/day
 No h/o dysmenorrhea, menorrhagia
 L.M.P. :29 July 2024

38.  Relationship and sexual history:
 Identifies as a female at age of 5 years, attracted to males
 Had no relationship till now
 No specifies fantasies were told by patient
 History of physical abuse at age of 12 years
 Other couldn’t be elicited as patient didn’t say on asking further.

39.  Marital history: unmarried
 No history of drugs and substance use

40. Premorbid Temperament
 Activity level:
 Regularly went to school
 Wake up at 7 Am
 She became ready for going school at 8 AM
 9:00 Am had food
 9:40 Am went school by herself
 4:00Pm return from school
 4-5 Pm had breakfast
 5-7 Pm goes to play games with her friend
 7-8 Pm did homework
 8:00 Pm had dinner
 9:00Pm went for sleep in bed
 Impression – energetic+

41.  Persistence and attention spans:
 She completed homework by herself in one seating after playing with her
friends.
 Impression – immersed+
 Distractibility :
 Could focus on homework even with surrounding noise and activity.
 Impression – Attentive+

42.  Sensory threshold:
 When doing homework and watching TV, she was not annoyed when family members
talk loudly and able to complete tasks
 Impression – Unaffected +
 Mood :
 When patients stayed with mother and father she would often spend time talking to
her mother and helping her around the house during activities.
 Impression - Positive

43.  Rhythmicity:
 Patients slept and wake at similar time everyday but some times had to told to sleep
on time, meals was at regular time and bowel habits are regular
 Impression – Regular+
 Approach:
 When meeting new people or guests at home,she greets them without being told
 Making friends is easy and mixed well with everyone in class peers and other family
members
 Impression – Withdrawal (open)

44.  Intensity:
 When guests and family members visited she often was cheerful and greeted them
 Impression – Exuberant+
 Adaptability:
 She is not fussy when things are not to her liking like meals and tends to eat whatever is given to
her.
 Impression-Accommodating
 Overall impression – Easy child

45. GENERAL EXAMINATION
Date of admission: 1st
Aug, 2024.
Date of examination : 1st
Aug, 2024.
Weight: 48Kgs Height: 5feet, 3 inches (163cms) BMI: 20.22 kg/m2
Vitals: Temperature: 98F Pulse: 78/min Respiration rate: 15breaths/min SPO2: 98% in room air BP: 110/80
mm/Hg
Pallor/Icterus/Lymphadenopathy/Cyanosis/Clubbing/Dehydration: Not seen
SYSTEMIC EXAMINATION:
 Cardiovascular: S1S2M0
 Respiratory: B/L Vesicular breath sounds, no added sounds
 Gastro-intestinal: Soft, non tender, no organs palpable, Bowel sounds 3/min

46. NEUROLOGICAL EXAMINATION
 Cranial Nerves:
 Olfactory: smell senses: Intact
 Optic:
 Visual Acuity 6/6
 Pupil 3mm equal B/L, circular, reactive to light
 Fundus Examination: Color/ shape/margin/ cup- Normal
 Oculomotor, Trochlear, Abducens
 Eyeball central in position, gaze intact in all directions
 Trigeminal:
 Muscles of mastication: intact
 Sensation over face: intact
 Corneal reflex: intact

47.  Facial nerve:
 Facial symmetry and movement of the face: intact
 Taste in anterior two-third of the tongue: intact
 Vestibulo-Cochlear:
 Rinne’s test: AC>BC
 Weber test: Not lateralised
 Glossopharyngeal and Vagus:
 Uvula-centrally located
 Gag Reflex: intact
 Cough on Command: intact
 Spinal Accessory:
 Trapezius and Sternocleidomastoid: shrugging: intact
 Hypoglossal:
 Inspection of tongue and tongue movements: Intact

48.  Motor System:
 Muscle bulk: B/L equal
 Involuntary movements: not present
 Muscle tone: Not increased or decreased
 Muscle power: 5/5 over all limbs
 Sensory:
 Light touch: Intact B/L equal
 Pain: Intact
 Temperature: Intact
 Vibration: Intact
 Joint position and movements: Intact

49.  Reflexes:
 Biceps: Normal
 Triceps: Normal
 Brachioradialis: Normal
 Knee: Normal
 Ankle: Normal
 Abdominal: normal
 Cremasteric: Normal
 Plantar: Flexion

50.  Cerebellar signs:
 Nystagmus : not present
 Scanning speech: not present
 Intentional tremors (finger-nose test): Normal
 Heel-shin test: Normal
 Dysdiadochokinesia: Normal
 Rebound phenomenon: Normal
 Pendular knee jerk: Not present
 Tandem walking or ataxic gait: Normal

51.  Cortical signs:
 Tactile localization: normal
 Two-point discrimination: normal
 Stereognosis: normal
 Graphesthesia: normal
 Meningeal Signs:
 Neck rigidity: not present
 Kerning’s Sign: not present
 Brudzinski Sign: not present
 Impression: No neurological deficits were noted

52. MENTAL STATUS EXAMINATION
 GENERALAPPEARANCE AND BEHAVIOUR
 An average mesomorphic built female appear to be in late ten’s which was
appropriate as stated, Wearing a khurta suruwal which was appropriately dressed
according to sex, climate and culture, well kempt hygiene and well groom, No
abnormal gait was noted, No abnormal facial expressions and Abnormal
movements absent, on Greeting replied Salam walikum, Eye contact was initiated
and maintained, Attitude was cooperative, Psychomotor activities was neither
increased or decreased, No catatonic behavior noted and Rapport was Established.

53.  Speech:
 Spontaneous , Coherent, Comprehensible
 Language: Hindi and Bhojpuri
 Rate: average
 Tone: Normal
 Pitch: Normal
 Volume: Normal
 Reaction Time: neither increased nor decreased

54.  Mood/Affect:
 Subjective= Q:तपाई को मन कस्तो छ?
 A: राम्रो छ।
 Objective=
 Quality: Euthymic
 Range: Broad
 Fluctuation: not present
 Reactivity: present
 Congruent to Thought: present

55.  Q.तपाई आफ्नो घर को बारेमा के हि भनु होस् ?
 A. मेरो घर यहि बिरगंज मा छ। घर मा बुवा,आमा, दिदि, भाई हरु छन्। सबै घर मा
मिलेर बस्छ। मेरो दिदि ले पनि मानसिक को औसदी खानु हुन्छ।
 Q.तपाई आफ्नो मन पर्ने चाडपर्ब को बारेमा भनु होस् ?
 A. मलाई मनपर्ने चाड पर्ब इदी हो। इदी मा सबै परिवार वसेर खान पहिन्छा। लामो
समय रोजा वसेर त्यो दिन मिठो परिकार हरु खान पाहिंछा।

56.  THOUGHT:
 Form:
 Derailment/ LOA: Not present
 Circumstantiality/Tangentiality: Not present
 Neologism: Not present Word Salad: Not present
 Flow :
 Tempo: Flight of Ideas/Retardation: Not present
 Continuity: Block : Not present / Perseveration: Not present

57.  Q:के तपाइलाइ वोरिपरि को मान्छे ले तपाइ को बारेमा कुरा गर्छन जस्तो लाग्छ।
 A: लाग्दैन।
 Q:के तपाई लाई लाग्छ जादू टूना गरेर तपाई लाई बस मा गरेको जस्तो लाग्छ ।
 A:लाग्दैन।
 Q: के तपाइलाइ ओरिपरि को मान्छे ले तपाई को बारेमा कुरा गर्छन जस्तो लागछ ?
 A: लाग्दैन।

58.  Q:कैले काई हजुर लाई जीवन बेकार छ , बाचेर के गर्नु लाग्छ ?
 A:मलाई सदै लाग्छ मेरो जीन्दगी बेकार हो बनेर र यो जीन्दगी संग बाच्न्नु भन्दा मर्न पाए भनेर सोच आउछ।
 Q:तेस्तो सोच कति भेला आउछ?
 A:मलाई सदै आउछ।
 Q:अनि तपाई ले आफ्नो मर्ने को लागि केहि सोच भनउनो भयको वा सोच्नु भयको छ अगाडी ?
 A:छैन तेस्तो।
 Q:तपाई लाई मर्नु को सोच आउनु मुखे कारण के हो ?
 A:मलाई आज भन्दा ६ बर्षे पहिले मलाई गाऊको मान्छे ले नराम्रो गरेको थियो। तेसैले गर्दा मलाई हरे समय त्यो कुरा
मात्र आउछ र मलाई अरु संग बोल्ने पनि डर लाग्छ। अनि कसरि यो कुरा अरु लाई भने र यो समाज ले मलाई के भन्छ
होला यो कुरा थाहा पाया पछि भनेर मेरो मन उदाश हुन्छ।

59.  Q:के तपाई लाई कुनै चिज वा कार्य गरेको पक्का हुदा पनि काम ठिक छ छैन भनि दोहेरयरा हेर्ने
गर्नु हुन्छ?
 A:मलाई डर लाग्छ रति अनि घर मा कोठा भन्दा गरेकी भनेर हेर्न जान्छु।
 Q:के को डर लाग्छ ?
 A:तेही घटना फे रि हुन्छ कि भने।
 Q:त्यो सोचे सदै आउछ कि ?
 A:आउछ अनि मलाई डर लाग्छ।
 Q:तपाई सफा सुन्दर हुदा पनि बारेम्बार धेरै बेर लागेर लुगा धुने , नुहाउने अर्थार्थ सरसफाई
बिशेस समय दिने गर्नु हुन्छ ?
 A:छैन तेस्तो।

60.  Content:
 Passive death wish +
 Preoccupied by stressor/event
 No delusion of persecution, reference
 No obsession

61.  Q.तपाईं लाई लाग्छ कि तपाईं को सोच आफ्नो हैन र कसैले दिमाग मा सोच राख्दियको
हो जस्तो लाग्छ ?
 A: लाग्दैन
 Q:तपाईंलाई लाग्छ कि बाहिर सक्ती ले तपाईं को सोचे लाई निकालेको जस्तो लाग्छ ?
 A:लाग्दैन
 Possession: No thought insertion, no thought withdrawal

62.  Perception:
 Q. तपाइ एक्लाई बसेको बेला कानमा मा आवाज आउछ ?
 A: आउदैन ।
 Q: अरु ले नदेखेको चिज तपाईंले मात्र देख्नोनु हुन्छ ?
 A: देखेदिना ।
 Q: के तपाईं लाई आफ्नो वोरिपिरि को चिज साचो हैन जस्तो लाग्छ ?
 A: लाग्दैन ।
 Impression: No hallucination and derealisation.

63. Cognition :
 Orientation:
 Time:
 Period of day: Afternoon
 Estimated time: 2 pm
 Day: Thursday
 Date : 01-Aug 2024
 Season: Summer
 Place:
 Country : Nepal
 City: Birgunj
 Place: National medical
 college
 Floor : first
 Ward : Psychiatry
 Person:
 Identity of accompanying informant asked,
identified as mother with correct name
 Impression : Oriented to time,place and person.

64.  Attention:
o Digit forward: 4 DF
o Digit Backward: 3 DB
 Concentration:
o Serial subtraction : Could do 100-7 upto 3 and then did mistake
In 40-3 did all without any mistake and took 1 minutes
In 20-1 did without any mistake and took 15 second
o Name of weeks :Could able to name the weeks and its reverse.
o Name of months & its reverse: Was able to do
 Impression: Arousable and Sustained

65.  Memory
o Registration and Recall (3 words): Intact i.e (सर्प , कलम र नदि )
o Immediate: Recall after 5 minutes in same order.
o Recent : Confirmed breakfast: Intact
o Remote:
 Year of birth : correctly confirmed
 Impression: Preserved

66.  Intelligence:
o Q : (Young girl handling an unexpected guest at home in absence of other family members)
o A: welcomed the guest.
o Simple calculations: could able to perform multiplication i.e 2* 3=6
o Complex calculation: patient was asked if you buy 10 apple in cost of 50? What would be cost
of each apple? The patient replied correctly i.e 5.
o Information and Fund of knowledge:
 Prime minister of Nepal:Thaya chaina
 3 big rivers: Narayani, Khosi and Bhagmati
 3 big city: pokhara, Kathmandu and chitwan
Impression: Average

67.  Abstract thinking:
o Similarity test
 Q: Apple and Orange
 A: फलफ
ु ल हो ,दुबै गोलो हुन्छ ।
 Q: Pencil and pen
 A: दुवै ले लेखन सकिन्छ ।
 Q: Aeroplane and bus
 A:दुवै ले मान्छे बोक्छ ।

68. o Proverb test:
 Q: नाच्न नजान्ने आग्न टेडा
 A: आफ
ु लाई क
े हि गर्न आउदिन अनि अरु लाई सिकाउछ।
 A. कालो अच्छ्यर भैसी बराबर ?
 B. आफ
ु लाई नआउने क
ु राहरु बुझ्न गारो हुन्छ।
 Impression : Intact

69.  Judgment:
 Personal Judgment: was done by asking question i.e घर गया पछि क
े गर्नु हुन्छ ? She
replied “घर को काम,पड्ने अनि औसधि खाने।”
 Social Judgment: behaviour was observed with other’s people in ward, doctor and
staff.(well behaved, cooperative and respect them in the ward.
 Test Judgment:
 Well stamped envelope test: ठेगाना छ भने खबर गरिदिन छु
 House on fire Test: आगो निमाउनो सहयोगे गर्छु
 Facing a snake suddenly test:भाग्छु
 Impression: Intact

70.  INSIGHT: Translated
 Q: Do you think there is anything the matter with you?
 A: Yes I have restless and headache.
 Q: Could it be a nervous condition?
 A: yes
 Q: what do you think the cause is?
 A: mental cause
 Q: Why do you need to come to hospital?
 A: To treat my restless and disturbed sleep.
 Q: Do you think this symptoms were part of a nervous condition ?
 A: yes
 Impression: Grade D

71. DIAGNOSTIC FORMULATION:
 Miss RK, 18 years unmarried Muslim, Studying in class 12th
class, unemployed by occupation, belonging
to lower middle socioeconomic status with past history of difficult in seeing near object under treatment
for 2 years with family history of suggestive of schizophrenia in father and in elder sister with easy child
premorbid temperament was admitted in psychiatric ward with target symptoms of consumption of non
nutritive substances that is brick,soil,ash which was persistent and severe enough to require clinical
attention with ability to distinguish between edible and non edible substances with exposure to extremely
threatening event(physical abuse) at 12 years of age and was re-experienced again and again in the form
of memories, repetitive dreams and images with flashback with fear of having episode again with low
mood, disturbed sleep, decreased interest in pleasure activites,hopelessness,worthlessness with
predisposing factor being positive family history of psychiatric illness in father and elder sister with
precipitating factor being physical abuse in children withpersonal history of decline in study due to
repeated flash back of events.
 On MSE revealing-ETEC initiated and maintain with linear and goal directed thought with preoccupied
by events with hopelessness,worthlessness, passive death wishes with insight to grade D

72.  Provisional diagnosis:
 ICD-11:
 6B84-PICA
 6B40-Post traumatic stress disorder

73.  Points favour for PICA
 Regular consumption of non nutritive substance
 Persistent or severe to require to clinical attention
 Based on age and level of intellectual function
 Points favour for PTSD
 Exposure to an event
 Re-experienced in the present
 Reminder likely to produce re-experiencing of the traumatic event are deliberately
avoided.
 Persistent
 Disturbed in personal,family,social and education

74. Management:
 Investigation
Sodium 137
Potassium 4.72
Blood Urea 15
Creatinine 0.66
RBS 87
TSH 2.678

75.  As the patient was complaint about pain in the head and watering from
the eyes the ophthalmic consultation was done.

76.  Final diagnosis:
 Pica with Post traumatic stress disorder

77. MANAGEMENT PLAN:
 Non pharmacological
 Pharmacological

78. Non pharmacological Approach
 Psycho-education to the patients party.
 Nutritional Counseling
 Environmental Modification
 PTSD Checklist for DSM-5 (PCL-5)=44

80.  Pharmacological Approach:
 Tab fluoxetine 20 mg and dose was increased upto 30 mg per day.
 Tab olanzapine 5mg per day at night
 Tab naproxen 250 mg po sos
 Tab clonazepam 0.25 mg po sos

81.  Plan
 CBT
 Behavioral Modification Therapy

82. CASE CONCEPTUALIZATION
Consumption of
non nutritive
substance at the age
of 2 years
Increasing age with
ability to distinguish
between edible to non
edible substance
Strong crave
for these
substance
that leads to
restless
Only relieved
crave after
eating
substance till
now
6 years back had
physical abuse
Reexperiencing
of events with
images and
flashback some
time during
dreams and
during day
time
Pica and PTSD

83. Topic of presentation

84.  Treatments for PICA
 Various treatments for pica including:
 Nutritional
 Psychological
 Pharmacological
 Behavioural interventions
 Ecological
 Sensory approaches
Stiegler, L. N. (2005). Understanding Pica Behavior: A Review for Clinical and Education Professionals. Focus on Autism and Other Developmental Disabilities, 20(1), 27-
38. https://doi.org/10.1177/10883576050200010301

85.  Treatment of PTSD
 Non-pharmacologic treatment for PTSD
emphasizes:
 shared decision-making and
collaborative care as vital early
interventions
 The primary recommendation for PTSD
treatment is trauma-focused therapy.
 Research also supports newer
therapies, including Cognitive
Behavioral Therapy for PTSD,
Narrative Exposure Therapy (NET),
and Written Exposure Therapy, which
have shown positive effects on PTSD
symptoms
 Pharmacologic treatment for PTSD
recommends SSRIs and SNRIs such as
fluoxetine, paroxetine, sertraline, and
venlafaxine.
Schrader C, Ross A. A Review of PTSD and Current Treatment Strategies. Mo Med. 2021 Nov-Dec;118(6):546-551. PMID: 34924624;
PMCID: PMC8672952.

86. Reference
 Stiegler, L. N. (2005). Understanding Pica Behavior: A Review for Clinical and Education
Professionals. Focus on Autism and Other Developmental Disabilities, 20(1), 27-38.
https://doi.org/10.1177/10883576050200010301
 Schrader C, Ross A. A Review of PTSD and Current Treatment Strategies. Mo Med. 2021
Nov-Dec;118(6):546-551. PMID: 34924624; PMCID: PMC8672952.

87. THANK YOU