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IGNOU Sample Internship File for MPCE015 GW

IGNOU Sample File for Internship MAPC - MPCE015 to help you understand how to do prepare your internship report faster and better. By GW. Good Luck!

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REPORT OF INTERNSHIP At LADY HARDINGE MEDICAL COLLEGE Presented to THE FACULTY OF THE DISCIPLINE OF PSYCHOLOGY, School of Social Sciences, IGNOU In partial fulfillment of the requirements for the degree of M.A. PSYCHOLOGY ADVISORS‐ MR. BY Enrolment no.
Page | 2 ACKNOWLEDGEMENT This internship would not have been possible without the kind support and help of my Seniors and Colleagues and I would like to extend my sincere thanks to all of them. I am highly indebted to for their valuable guidance and constant supervision during my internship at Lady Hardinge medical college. I would like to express my gratitude towards my Teacher for their constant motivation and guidance.
Page | 11 CONTENTS INTRODUCTION .............................................................................................12 HISTORY OF THE INSTITUTION.................................................................12 SAMPLE CASE FORMAT ...............................................................................14 CASE‐ I..............................................................................................................20 CASE‐ II.............................................................................................................27 CASE‐ III............................................................................................................34 CASE‐ IV............................................................................................................39 CASE‐ V.............................................................................................................44 CASE‐ VI............................................................................................................51 CASE‐ VII...........................................................................................................56 CASE‐ VIII..........................................................................................................61 CASE‐ IX............................................................................................................66 CASE‐ X.............................................................................................................72 DISCUSSION.....................................................................................................78 REFERENCES....................................................................................................79
Page | 12 INTRODUCTION Internship is an important component of the MA Psychology Programme of IGNOU. This internship was carried out for a period of 240 hours under the constant supervision of , Director, Professor Head and Consultant Child Psychiatrist, Psychiatry Service for Children, Adolescent & Adults and De‐addiction Centre, in Lady Hardinge Medical College, New Delhi‐110001. OBJECTIVES OF INTERNSHIP ƒ To provide comprehensive training in field of psychology. ƒ To help develop skills and techniques to provide the needed services to individuals, groups and organizations as a psychologist. ƒ To develop professional competence as a psychologist. ƒ To encourage the learner to maintain the highest standards in offering the psychological services. SELECTION OF AGENCY FOR INTERNSHIP The psychiatric department of Lady Hardinge Medical College, a renowned medical college, was chosen for pursuing internship. HISTORY OF THE INSTITUTION The Lady Hardinge Medical College, a pioneer in the field of Medical Education has the unique distinction of being the only Medical College in India, for exclusively training women undergraduate students. The college was founded by Lady Hardinge of Penhurst, the wife of the Viceroy of India, in order to overcome the orthodox trends prevailing the contemporary India, amongst the parents’ minds against educating their daughters in co‐educational Colleges. She used her good offices to raise funds from the Princely States & the Public. The Institution was formally opened by Lord Hardinge in February 1916. The doctors who have tread the paths of this college have achieved fame worldwide. They have risen to key positions and outshone in their respective fields, like Dr. Sushil Nayar, Dr. Usha Luthra of I.C M.R., Dr. Sumedha Khanna of W.H.O. Dr. Saroj Pachauri of Ford Foundation. The College started under the able leadership of Dr. Kate Platt M.D, who was the first Principal of the College. At present the Director of the college
Page | 13 is Dr. G.K. Sharma. The College has coma long way, retaining its unique character, still marching ahead with the times and is upgrading itself dynamically in all its fields of activities. Since its inception, the institution has produced 6125 graduates and 2564 postgraduates in various medical and surgical specialities. The students and faculty have constantly strived for academic excellence, state‐of‐the‐ art health care provision, and high quality research competing with the best in the country. For the teaching and training of medical students, the college has two full fledge hospitals‐ Smt. Sucheta Kriplani Hospital, and Kalawati Saran Child Hospital with bed strength of 877 and 350 respectively. All the department of the hospitals are equipped with modern facilities to provide tertiary level health care services to the people of Delhi & adjoining areas. Since 1991 the hospital has been providing care to the male clients also. The Psychiatric Department is headed by , Director, Professor Head and Consultant Child Psychiatrist, Psychiatry Service for Children, Adolescent & Adults and De‐addiction Centre. BRIEF DESCRIPTION OF THE INTERNSHIP Internship under , Department of psychology, was started from The internship included taking whole case history of the patient as far as can be elicited with an aim to arrive at the most probable causation and diagnosis of the disorder. The cases taken by the interns were then described to the agency supervisor for further suggestive investigations, pharmacological and therapeutic interventions.
Page | 14 SAMPLE CASE FORMAT Client’s Name‐ Date Registration no‐ Age‐ Gender‐ Address‐ Educational qualifications‐ Occupation‐ Income‐ Marital status‐ Clients stay with parents‐ Stay with Spouses‐ Siblings, how many Position in family‐ eldest/youngest/ middle/only child Anyone in family suffered from mental disorder Anyone in family suffered from physical disorder Informant • Relation‐ • Source of Referral‐ Presenting complaint (in words and as in sequence told by the client) History of Present Illness‐ • Onset‐ • Treatment taken‐ • Got well any time in between, duration of such period • Was there any precipitating factor at each relapse? • How many relapse • Any other treatment tried in between‐ • Effect of treatment‐ • Impact of illness on daily life‐ • Has to take leave from work place/ school/ college‐ • Cannot carry on routine work‐
Page | 15 • Has to depend on others for everything‐ • Want to lie down and take rest‐ • Don’t want to do anything‐ • Others Interview with family members • Relationship‐ • Their view point‐ • In what ways illness caused inconvenience to them‐ • Educational history of client‐ • School / college‐ • How is academic performance‐ • Does client matches parents and teachers expectations‐ • How has the performance been over years? • Any sudden deterioration in performance • Any complaints received • Has they done anything so far to correct it? What? Past History Family History Mental status examination (except in coma and unconscious clients/client with unknown language) Presentation Personal appearance Social interaction with staff and others in waiting room If someone accompanying and who Personal grooming Hygiene‐ If client dressed according to season appropriate Talking to himself in waiting room Pacing up/down the office floor Rapport building Appearance – if interested in self and grooming/ able to take care of self Movement and behavior
Page | 16 1. Gait 2. Posture 3. Coordination 4. Eye contact 5. Facial expressions 6. Walking / coordination problem if any Affect Over reaction / lack of response Mood ‐clients answer‐ sad/ happy/ angry Speech Volume Rate/speed Length of answers Appropriateness of answers Clarity of answers Thought content Hallucinations • Do you hear some voices telling you something to do? • Do you hear some voices when no one present? • Do you feel someone is talking about you and loudly saying whatever u doing Delusions • Do you feel people are after you? • Do you sometimes feel people are talking about you? • Do you sometimes feel your phone is tapped • Do you feel people are overhearing your conversation? Dissociation • What is your name • Who are you? • What work you do? • Do you sometimes feel that you don’t know who you are? Obsessions‐ • Any particular thought come into your mind again and again? • Sometimes a strange idea or feeling comes in your mind, which is not correct and how much you try the though don’t go off • Any impulse to clean, wash hands, locks on doors repeated
Page | 17 Thought process • Irrelevant details • Repeated words phrases • Interrupted thinking • illogical connections Cognition • Orientation – T/P/P • Long term memory • Short term memory • Ability to perform a simple arithmetic task • General intellectual level • Ability to think abstractly • Ability to name specified substances/ read / write complete sentences • Ability to understand and perform a task • Ability to draw a simple map or copy a geometrical figure • Inability to tell right left Judgment – ask commonsense problem (as running out of a prescription medicine, or find a sealed envelope on floor) Insight – do you think you are ill? • Any improvement with their efforts? • When did they decide to consult a mental health specialist? Work history • Occupation • Regular on work? • Any complains of workplace? What? • Any leaves? How long? • Anytime reluctant to go to office? • When was the time when client was reluctant? • Reasons given by client for not attending work? • Any complaint of performance? • Client relationship with people in workplace • Boss • Colleagues
Page | 18 • Subordinates • Anyone bothering at workplace Marital history • Day to day dealings • Sex life • Work relationship (spouse is working if) • Relationship with children • Relationship with opposite sex • Decision making • Sharing of work at home • Relationship with spouse’s relatives • Relationship with spouse’s friends • Answers to be in verbal language? How was client answering? • Hesitant? • Free communication? • Evading any answer? • Focusing on interview • Diverted easily distracted • Have the questions to be repeated no of times • General demeanor of client • Was client in hurry/ unwilling to continue interview • Pause in certain questions • Cooperative ready to answer • Showing concern about his illness? Summary Provisional Diagnosis Differential diagnosis Suggested interventions
Page | 19 CASE STUDIES
Page | 21 along with them. The complaints started after the Elder Brother got married, a sum of 5 lac rupees was taken on Loan from a nearby Seth for the marriage. But suddenly a change in behavior of the elder brother was noted after marriage he started becoming aloof and stopped talking to the other family members. The Money lender put pressure on the family for getting his money back, but the elder brother showed no concern and quarrels started happening between the client’s father and the elder brother. The elder brother said that he won’t be giving any money and all pressure came upon the client’s father, the client’s father a alcoholic started getting more angry and everyday there were quarrels going on in the house. The client is concerned about the pressure on the father and gets scared from the fights which happen in the family. Though she was closest to the elder brother she felt much neglected as the elder brother stopped talking to her and her family properly after marriage. The client said ` wo baat nai karte, seethe upar apne kamre mein chale jaten hai, badal gaye hain’. She says ‘ab wo ghar mein paise bhi nai dete’. She says ‘bhabhi mana karti hai unhe baat karne se’, ‘bhabhi khud bhi theek se baat nai karti, ‘ladai karati hai’ When enquired about the earning members it was elicited • 1st sibling‐ the elder brother is doing Tent work. gets about 10,000 money per month. • 2nd sibling sister is married • 3rd sibling sister ‐ who use to work has also left her work and is now all day at home, • 4th sibling had joined some mobile shop, but goes on and off, so he earns only when he goes • She is the 5th child • And 6th sibling sister is in school in 12th class Gradually the client started feeling very anxious and developed palpitations. she said sone lagti hun to ghabrahat hoti hai , koi bhi awaaz a jaye to darr lagta hai. Dimaag mein khayaal ate hain har waqt’. She is thinking about how the financial condition could be stabilized how the loan could be payed. She was taking tuitions for all subjects at home since 2 months from which she could just get a meager amount of 1350/‐. She has her exams in June now and is now also tensed about her exams, she said she had to fill her fees in college for giving exams but she gave the
Page | 22 money to papa as they wanted it. She is very much anxious with the financial constraint of the family. She is anxious about how her fees will be filled and if she will be able to give the exams and if she will pass the exams and her year is not spoiled. She says ‘mummy sunti nai hai, mein bolti hun parr wo sunti nai hai’ The client is having tension and anxiety from any sudden noise, is crying very often most of the times when alone, as she feels helpless. Her Appetite is decreased, eats one chappati, she feels angry but is unable to express it. The client hasn’t slept since 8 Days. • Onset‐ 6 months back • Treatment taken‐ No Treatment Taken • Got well any time in between, duration of such period‐ No • Was there any precipitating factor at each relapse? After the marriage of Elder Brother (Financial Problems grew and brother also became indifferent) Symptoms increase after quarrels at home • Impact of illness on daily life‐ the client is not able to concentrate on her studies, her exams is in June, but she is all time engrossed in thoughts about the financial constraint Interview with family members • Relationship‐ Mother • Educational history of client‐ Ist year student • Their view point‐ The client thinks a lot due to which she could not sleep, she hasn’t slept at all since 8 days, gets awake at night and say she is anxious • In what ways illness caused inconvenience to them‐ No inconvenience but they are concerned as the client is not well Past History‐ Nothing Significant Family History Father is a chronic alcoholic; else all family members are apparently healthy.
Page | 23 Mental status examination Presentation‐ Dressed in simple clothes as per season, hair groomed, hygiene maintained Personal appearance‐ Neat and Clean Social interaction with staff and others in waiting room‐ Yes. If someone accompanying and who‐ Brother and Mother Talking to himself in waiting room‐ No, Sitting quietly Pacing up/down the office floor‐ No Rapport building‐ rapport was build by asking to sit comfortably and relax. After the client was seated comfortably she was asked as per what is the problem empathetically. Appearance – if interested in self and grooming/ able to take care of self‐ Yes Movement and behavior 7. Gait‐ Nothing abnormal detected 8. Posture‐ Nothing abnormal detected 9. Coordination‐ Present 10. Eye contact‐ Present 11. Facial expressions‐ Sad, anxious 12. Walking / coordination problem if any‐ No Affect‐ Decreased response to whatever happening in the room Mood ‐clients answer‐ Sad Speech‐ Normal, no difficulty noted Volume‐ Slow Rate/speed‐ slow Length of answers‐ neither too short nor too long. Appropriateness of answers‐ Yes Clarity of answers‐ Yes Thought content‐ Positive Hallucinations‐ No Delusions‐ No Dissociation‐ No Obsessions‐ No Thought process‐ No Irrelevant details, repeated words phrases, interrupted thinking or illogical connections. Clear thought. But interrupted thoughts due to concern about the family financial condition.
Page | 24 Cognition • Orientation – Well Oriented to Time/People and Place • long term memory‐ Intact • short term memory‐ Intact • ability to perform a simple arithmetic task‐ Yes • general intellectual level‐ Average • ability to think abstractly‐ Yes • ability to name specified substances/ read / write complete sentences‐ Yes • ability to understand and perform a task‐ Yes • ability to draw a simple map or copy a geometrical figure‐ Yes • inability to tell right left‐ Yes Judgment – ask commonsense problem (as running out of a prescription medicine, or find a sealed envelope on floor)‐ Yes Insight – do you think you are ill‐ Yes Work history • Occupation‐ Taking tuitions for all subjects since 2 months • Regular on work? Yes • Any complains of workplace? What? She can’t concentrate on teaching children • Any leaves? How long? Yes , she is sometimes asking students to come later, but she can’t do it always, as they will then stop the tuitions , so the client is concerned • Anytime reluctant to go to work? Yes, as she can’t concentrate and also she have to study for her exams also • When was the time when client was reluctant? Yesterday • Reasons given by client for not attending work? she can’t concentrate and also she have to study for her exams also • Any complaint of performance? No • Client relationship with people in workplace‐ Ok • Anyone bothering at workplace No Marital history‐ Unmarried • Answers to be in verbal language? How was client answering? Yes • Hesitant? No
Page | 25 • Free communication? Yes • Evading any answer? No • Focusing on interview‐ No • Diverted easily distracted‐ No • Have the questions to be repeated no of times‐ No • General demeanor of client‐ very laid back and tired, looking dull • Was client in hurry/ unwilling to continue interview‐ No • Pause in certain questions‐ Yes occasional. • Cooperative ready to answer‐ Yes • Showing concern about his illness? Yes Summary The client is a 18 year female suffering from anxiety and palpitation since 6 months. She is sleepless and all the time thinking about the financial constraints because of which she can’t concentrate on her studies and tuition students also. The anxiety and palpitations increase after any episode of quarrel at home. Provisional Diagnosis Adjustment Disorder with Anxiety Differential diagnosis • Depressive disorders: Absence of sad, empty, or irritable mood, ccompanied by somatic and cognitive changes that significantly affect the individualʹs capacity to function. • Post traumatic stress disorder: Absence of any trauma, or any recurrent intrusive thoughts about any traumatic event, dissociative reactions, flashblacks, avoidance to any stimuli associated with any traumatic event. • Personality Disorder: Absence of lifetime history of personality functioning, vulnerability to distress, stressors may also exacerbate personality disorder symptoms. Suggested interventions • Pharmacotherapy – Mood stabilizers were prescribed.
Page | 26 • Cognitive behavior therapy‐ She was asked questions to increase her cognitive thinking processes and again talked about her responsibilities and courier and talked about to increase her thinking process. She has been admitted, her mother is asked to bring her books here so she can study here only. A time table was prepared for her to follow( till she is in the In client department) so that she could effectively manage her time in studies • Deep Relaxation therapy‐ Including breathing exercises, focused muscle tensing and progressive muscle relaxation techniques to decrease anxiety and provide mental relaxation. A session of Progressive muscle relation therapy was done with the client. By asking her to close her eyes and try to relax the mind. She was asked to take deep breaths. She was then asked to focus all her attention on the left foot and to tighten it as much as possible, then she was asked to relax it and similarly she was one by one asked to focus on different parts of the whole body. After the session she feels little more at ease and relaxed than before. She was asked to do the same exercise at home before sleeping at night. Follow Up The client was admitted in In‐Client department to seclude her from the home environment. She has Slept last night after the medicine. But she is anxious and palpitations occur at night. client complains of thoughts about home coming in mind. She can’t concentrate on studies because of the thoughts. She hasn’t done the relaxation exercise in the night. She is asked to do it regularly. Sleep has improved. She is less anxious now. Is doing the relaxation exercise in night. She wants to go home and was discharged. A time table has been prepared for her so that she can manage her time in home and can spare as much time as possible for studying. She has been asked to focus on her studies only and not to think very much and leave the big decisions to elders. Her mother and brother have been asked to be supportive to her.
Page | 27 CASE‐ II Client’s Name‐ Date‐ Registration No‐ Age‐ 17 years Sex‐ Female Address‐ Educational qualifications‐ 1st year Student Occupation‐ None, presently 1st year Student Marital status‐ Unmarried Client stay with parents‐ Yes Stay with Spouses‐ Not Applicable Siblings, how many‐ 2 sisters and 2 brothers Position in family‐ Fourth Child Anyone in family suffered from mental disorder‐ Mother had a history of maniac symptoms and was admitted 4 years back in lady Hardinge medical hospital Anyone in family suffered from physical disorder‐ Mother undergoing treatment for arthritis and thyroid disorder. Informant Relation‐ Father Source of Referral ‐ Self Presenting complaint (As told by the informant) • Not talking • Gum sum rehti hai • No Appetite • Crying and laughing Presenting complaint (As told by the client) Client did not told any complaint so the informant was asked about what happened and history was taken from the informant, then the client was interrogated for more information.
Page | 28 History of Present Illness‐ Client was apparently well 4 days back she was stressed and studying day and night for exams, was not sleeping properly and taking her meals properly, father concerned about the same scolded the client and slapped the client once and didn’t talked with her for 2 days, since then the client had stopped talking normally and is now less cheerful. She is eating less and only when father feeds her, having vertigo and weakness and insomnia. Premorbid behaviour‐ cheerful and talkative. The client says “I am mad” she refuses that she was scolded by her father. Client is sitting quietly in a side. • Date of onset of illness‐ 4 days back • Treatment taken‐ Nothing • Got well any time in between, duration of such period‐ No • Was there any precipitating factor at each relapse? The client was slapped and scolded by the father and also the father didn’t talked with the client for 2 days (the client was most closest to the father and the father had never scolded or talked with her in high tone) • How many relapse‐ the problem is persisting since 2 days. • Any other treatment tried in between‐ No treatment taken • Effect of treatment‐ Not Applicable • Impact of illness on daily life‐ The client had her exams coming and now her study is getting affected. • Has to take leave from work place/ school/ college‐ On a later follow up it was seen that she dint appeared for her exams • Cannot carry on routine work‐ Yes, earlier she was studying day and night for exams, not eating properly but since the incident the client is now quiet and sitting, not studying. • Has to depend on others for everything‐ No • Want to lie down and take rest‐ No • Don’t want to do anything‐ No • Others‐ She is now quiet and not talking. She is not as cheerful as before. Interview with family members • Relationship‐ Father
Page | 29 • Their view point‐ On questioning the father about the most probable reason for her change of behavior the father said that it’s because of him as he dint ever scolded the child and she has got a shock after he scolded, slapped her and dint talked to her. • In what ways illness caused inconvenience to them‐ the child is now not as cheerful as before and also could not study, they are concerned if her exams and studies will get affected. • Educational history of client‐ College • School / college‐ Government Girl Senior secondary school • How is academic performance‐ Average (Getting 70% marks) • Does client matches parents and teachers expectations‐ No • How has the performance been over years? Average • Any sudden deterioration in performance‐ Yes since 4 days is not able to concentrate • Any complaints received‐ Not gone to school after the incident • Has they done anything so far to correct it? What? Brought to the hospital for treatment and consultation. • When did they decide to consult a mental health specialist? When after 2 days she wasn’t behaving normally. Family History All members are apparently well. Mother had a history of manic symptoms 4 years back (started from 6‐7 days sleeplessness, headache, laughing, talking, tearing clothes) for which treatment was taken from lady Irwin medical college, and also taking treatment for Thyroid disorder.
Page | 30 Mental status examination Presentation‐ The client was well dressed and groomed suitable to the occasion and season Social interaction with staff and others in waiting room‐ Very less interaction, talks only when asked something. If someone accompanying and who‐ Father Talking to himself in waiting room‐ No Pacing up/down the office floor‐ No Rapport building‐ Rapport was build with the clients by making her comfortable by politely asking her about her complaints and daily life and taking her outside for a casual walk so as to relieve her tension. After this the client seems comfortable and was smiling and happy. Appearance – if interested in self and grooming/ able to take care of self‐ Yes. Movement and behavior 1. Gait‐ Body very stiff, very stiffness seems on walking; client seemed much tensed and was not able to relax. 2. Posture‐ Stooped shoulders while walking 3. Coordination‐ Proper and intact 4. Eye contact‐ Intact 5. Facial expressions‐ Decreased facial expression 6. Walking / coordination problem if any‐ No Affect‐ Decreased, low sad mood, Blankness of face Mood ‐clients answer‐ Blank expression Speech‐ decreased Volume‐ Low Rate/speed‐ Low Length of answers‐ Short Appropriateness of answers‐ Yes Clarity of answers‐ Yes Thought content‐ Present, but slow, takes time to answer Hallucinations‐ No Delusions‐ No Dissociation‐ No Obsessions‐ No Thought process‐ Normal, no intrusive thoughts.
Page | 31 Cognition • Orientation – Well oriented to Time/People/Place • Long term memory‐ Intact • Short term memory‐ Intact • Ability to perform a simple arithmetic task‐ Intact • General intellectual level‐ Intact • Ability to name specified substances/ read / write complete sentences‐ Intact • Ability to understand and perform a task‐ Intact, but slow++ • Ability to draw a simple map or copy a geometrical figure‐ Intact • Inability to tell right left‐ Intact Judgment‐ Present Insight – Do you think you are ill? Not clear Marital History: Unmarried Work History: Not Applicable as student • Answers to be in verbal language? How was client answering? Yes • Hesitant? No • Free communication? Yes • Evading any answer? No • Focusing on interview‐ Yes • Diverted easily distracted No • Have the questions to be repeated no of times? Yes sometimes • General demeanor of client‐ Lack of emotions and response • Was client in hurry/ unwilling to continue interview‐ No • Pause in certain questions‐ Yes, the client was asked to write her name in different languages she wrote in English and Hindi and when asked to write in Urdu which is also one of her subjects and in which she is getting good marks in the subject, she suddenly paused and said slowly no she don’t know how to write in Urdu. She wanted to join Zakir Husain College, ( An Urdu Medium School) but when asked to write Urdu she says she don’t know. On insisting by mother she wrote her name lastly.
Page | 32 • Cooperative ready to answer‐ Yes • Showing concern about his illness? No Summary The client is a 17 year old female enrolled in 1st year of college, who was approaching exams. Due to her high expectations she was stressed a lot and busy studying day and night for exams, not sleeping or eating properly because of which father scolded and slapped by her. But since then she has developed sudden change in behavior from premorbid cheerful personality to now remaining quiet and aloof and not sleeping at all. Provisional Diagnosis Adjustment Disorder Differential Diagnosis • Depressive disorders: Absence of sad, empty, or irritable mood, ccompanied by somatic and cognitive changes that significantly affect the individualʹs capacity to function. • Post traumatic stress disorder: Absence of any recurrent intrusive thoughts about any traumatic event, dissociative reactions, flashblacks, avoidance to any stimuli associated with any traumatic event. • Personality Disorder: Absence of lifetime history of personality functioning, vulnerability to distress, stressors may also exacerbate personality disorder symptoms. Interventions Done • Pharmacotherapy – Mood stabilizers were prescribed. • Cognitive behavior therapy‐ She was asked questions to increase her cognitive thinking processes and again talked about her responsibilities and courier and talked about to increase her thinking process.
Page | 33 • Deep Relaxation therapy‐ Including breathing exercises, focused muscle tensing and progressive muscle relaxation techniques to decrease anxiety and provide mental relaxation. A session of Progressive muscle relation therapy was done with the client. By asking her to close her eyes and try to relax the mind. She was asked to take deep breaths. She was then asked to focus all her attention on the left foot and to tighten it as much as possible, then she was asked to relax it and similarly she was one by one asked to focus on different parts of the whole body. After the session she feels little more at ease and relaxed than before. She was asked to do the same exercise at home before sleeping at night. Follow up The client seems better and cheerfulness has increased. The client has not given the exams and is saying she will give exams after 2 months after full preparation. She is positive and ambitious about her marks.
Page | 34 CASE‐ III Client’s Name‐ Date‐ Registration no‐ Age‐ 7 years Gender‐ Female Address‐ Educational qualifications‐ Not gone to school Marital status‐ Unmarried Client stay with parents‐ Yes Stay with Spouses‐ No Siblings, how many‐ 1 elder brother (11 years) and 1 sister (7 years) Position in family‐ eldest/youngest/ middle/only child‐ Younger Anyone in family suffered from mental disorder‐ No Anyone in family suffered from physical disorder‐ No Informant Relation‐ Mother Source of Referral ‐ Relatives Presenting complaint (in words and as in sequence told by the client) • Paper khati hai • Kehna nai manti • Paglon ki tarah rehti hai History of Present Illness‐ Client was a full term normal vaginal delivery, with birth cry present, birth weight – 2.5 kg. The child was increasingly active since birth, don’t use to listen or obey. In class don’t use to do work, tears paper, writing on it, gets 10‐15 out of 20.the client’s behavior is full of anger, shouting, when mother sleeping she do mischief, takes creams violini and lips. The client don’t play with other children, use of hits other children, say to others that her mother hits her. Dresses like teacher. Plucking of hairs (Alopecia due to
Page | 35 trichotillomania). The complaints increase in summer weather. Sleep good (10 pm‐ 9am) eats papers since 1‐2 Days. • Date of onset of illness‐ since childhood. • Treatment taken‐ No treatment taken so far • Got well any time in between, duration of such period‐ N/A • Has to take leave from work place/ school/ college‐ N/A • Cannot carry on routine work‐ Yes • Has to depend on others for everything‐ No • Want to lie down and take rest‐ Yes Interview with family members • Relationship‐ Mother • Educational history of client‐ KG class • School / college‐ GRM Public Senior secondary School • How is academic performance ‐ Average, 10‐15 out of 20 • Does client matches parents and teachers expectations‐ Yes • How has the performance been over years? In KG Class • Any sudden deterioration in performance‐ No • Any complaints received‐ Hits other children in class, doesn’t Sits/stay at one place. • Has they done anything so far to correct it? What? No • When did they decide to consult a mental health specialist? When someone told her to come here and take treatment from here. Past History‐ Nothing Significant Family History‐ No history of any mental/ Physical disorder in family. All apparently healthy and alive Mental status examination Presentation‐ The client is well oriented, friendly, and well‐groomed, under shirt visible and is over the dress. A hairless patch noted on the scalp. Dressed as per the season. Hygiene maintained. Social interaction with staff and others in waiting room‐ Greeting the staff. Greeting all the interns she knew as ‘ Hi didi’ ‘Hi didi’
Page | 36 If someone accompanying and who‐ Mother Talking to himself in waiting room‐ No Pacing up/down the office floor‐ Yes, running all over the place, not sitting for long at one place. Rapport building‐ Rapport was build by greeting the client and asking her some basic questions about herself. Appearance – if interested in self and grooming/ able to take care of self‐ Yes Movement and behavior 13. Gait‐ Nothing abnormal Detected 14. Posture‐ Nothing abnormal Detected 15. Coordination‐ Nothing abnormal Detected 16. Eye contact‐ Present 17. Facial expressions‐ as if getting bored. 18. Walking / coordination problem if any‐ No Affect‐ Elated mood Mood‐ Happy Speech‐ Can’t pronounce words from `La’ and `ra’, Language articulation Problem Volume‐ High Rate/speed‐ Normal Length of answers‐ Short Appropriateness of answers‐ Yes Clarity of answers‐ Unclear Thought content‐ Clear, Normal, Listening, Obeying, understands the situation, no Intrusive thoughts Hallucinations‐ No Delusions‐ No Dissociation‐ No Obsessions‐ No Thought process‐ Clear • Irrelevant details‐ No • Repeated words phrases‐ No • Interrupted thinking‐ No • illogical connections‐ No
Page | 37 Cognition • Orientation – Well oriented to time, people and place • Long term memory‐ Intact • Short term memory‐ Intact • Ability to perform a simple arithmetic task‐ Yes • General intellectual level‐ Average • Ability to think abstractly‐ Yes • Ability to name specified substances/ read / write complete sentences‐ Yes, can name sentences, can’t write full sentences, can write basic alphabets and numbers. Macrographia, writing big. • Ability to understand and perform a task‐ Yes • Ability to draw a simple map or copy a geometrical figure‐ Yes • Inability to tell right left‐ Yes Judgment and Insight– Present as per age Work history‐ Not applicable Marital history‐ Not applicable • Answers to be in verbal language? How was client answering? Yes • Hesitant? No • Free communication? Yes • Evading any answer? No • Focusing on interview‐ Yes, but easily distracted • Diverted easily distracted‐ yes • Have the questions to be repeated no of times‐ No • General demeanor of client‐ • Was client in hurry/ unwilling to continue interview‐ No • Pause in certain questions‐ No • Cooperative ready to answer‐ Yes • Showing concern about his illness? No
Page | 38 Summary Client is a 7 year old female child with hyperactive behaviour and tendency to pluck the hair which has lead to a Hairless patch on the scalp. Provisional Diagnosis Attention deficit Hyperactivity disorder with trichotillomania Differential diagnosis • Oppositional defiant disorder: Absence of any negativity, hostility, and defiance. No resistance to tasks given is observed • Specific Learning Disorder: No serious concern noted in learning and using acaedemic skills. • Reactive attachment disorder: Absence of inhibited, emotionally withdrawn behavior toward adult caregivers. High social and emotional responsiveness to others.Good history of caregiving. Suggested interventions • Pharmacotherapy‐ To Decrease Hyperactivity • Family therapy‐ To increase family support • Behavior modification therapy‐ To increase wanted behavior and decrease unwanted behavior.
Page | 39 CASE‐ IV Client’s Name‐ Date‐ Registration no‐ Age‐ 12 Years Gender‐ Male Child Address‐ Educational qualifications‐ 3rd Standard Occupation‐ Student ‐ Marital status‐ Unmarried Clients stay with parents‐ Yes Stay with Spouses‐ No Siblings, how many‐ One Younger brother Position in family‐ Elder Child Anyone in family suffered from mental disorder‐ No Anyone in family suffered from physical disorder‐ grandfather paralyzed at 60 years, Clients maternal uncle had history of seizures. Informant Relation‐ Father Source of Referral‐ Relatives Presenting complaint (in words and as in sequence told by the Father) • Dimaag mein kami hai • Jhooth bolta hai • Khana nai khata, Kamzor hai History of Present Illness‐ The client was born as a full term normal vaginal delivery at home, Birth cry positive, Birth weight‐ 750 g (Pauna kilo). The mother had weakness in extremities, Body ache, Heaviness from beginning of 2nd trimester. There were financial strains and tensions during pregnancy as no one was working then. The child was admitted 12 hours after birth due to fits, for which he was treated for 22 days in the ICU. Then he was brought home, where he developed diarrhea, vomiting. For which again allopathic treatment was started and it got well. The client had his milestones on
Page | 40 time. The client is now 20 Kg. Schooling since 3‐4 years, the child is very notorious in school doesn’t do work at school. • Date of onset of illness‐ Subnormal intelligence noted since he started going school • Treatment taken‐ No Treatment taken • Has to take leave from work place/ school/ college‐ No • Cannot carry on routine work‐ Can do routine work. • Has to depend on others for everything‐ No • Want to lie down and take rest‐ No Interview with family members • Relationship‐ Father • Educational history of client‐ attended school till 3rd class • School / college‐ Going to school, but poor performance • How is academic performance ‐ Poor • Does client matches parents and teachers expectations‐ No • How has the performance been over years? Not improved • Any sudden deterioration in performance‐ No, Bad from starting • Any complaints received‐ Yes, don’t study, roams in the class • Has they done anything so far to correct it? What? No • Any improvement with their efforts? No • When did they decide to consult a mental health specialist? • Their view point‐ As per the father the child is very weak in studies, can’t study as a normal child, and is very dull. • In what ways illness caused inconvenience to them‐ No such inconvenience as such but they are just concerned about the child’ intellect and his future, what will he do, if he will be dull. Past History‐ Client born as underweight child. Family History‐ All apparently well Mental status examination Presentation‐ Poor Hygiene, dressed well as per the season but looking dirty, Infective itching rash over face and neck. Personal appearance‐ dirty Social interaction with staff and others in waiting room‐ present
Page | 41 If someone accompanying and who‐ father Personal grooming‐ hair nicely groomed Talking to himself in waiting room‐ No Pacing up/down the office floor‐ No Rapport building‐ rapport was build by making the client sit comfortably and asking the client his name and what does he do. Appearance – if interested in self and grooming/ able to take care of self‐ Less interested Movement and behavior 19. Gait‐ Nothing Abnormal detected 20. Posture‐ Nothing Abnormal detected 21. Coordination‐ Intact 22. Eye contact‐ Intact 23. Facial expressions‐ Nothing Abnormal detected 24. Walking / coordination problem if any‐ No Affect and Mood‐ Normal neither too happy nor sad Speech‐ No speaking difficulty, normal speech but repeating end of questions. Volume‐ Low Rate/speed‐ Normal Length of answers‐ short but appropriate length Appropriateness of answers‐ Yes Clarity of answers‐ Yes Thought content‐ Normal, No Intrusive thoughts Hallucinations‐ No Delusions‐ No Dissociation‐ No Obsessions‐ No Thought process‐ Slow • Irrelevant details ‐ Absent • Repeated words phrases‐ Thinks and repeats questions, repeating end of questions like when asked to tell a story he said kahani sunaun, kahani sunaun, when as what does he like to eat ~ he said `mujhe lagta hai, lagta hai’ • Interrupted thinking‐ No, Absent • Illogical connections‐ No
Page | 42 Cognition • Orientation – Client well oriented to people, place and time • Long term memory‐ Intact • Short term memory‐ Intact • Ability to perform a simple arithmetic task‐ No • General intellectual level‐ Below Normal • Ability to think abstractly‐ No • Ability to name specified substances/ read / write complete sentences‐ Decrease intellect can write words or sentences • Ability to understand and perform a task‐ yes, verbal tasks • Ability to draw a simple map or copy a geometrical figure‐ yes can draw a circle • Inability to tell right left‐ Yes Judgment –Intact Insight –Intact Work history‐ None Marital history‐ Unmarried • Answers to be in verbal language? How was client answering? Yes • Hesitant? ‐ No • Free communication? Yes • Evading any answer? No • Focusing on interview‐ Yes • Diverted easily distracted‐ No • Have the questions to be repeated no of times‐ No • General demeanor of client‐ slow • Was client in hurry/ unwilling to continue interview‐ No • Pause in certain questions‐ Yes in all questions requiring thinking • Cooperative ready to answer‐ Yes Summary The client is a 12 year male child with decrease scholastic performance as per his age.
Page | 43 Provisional Diagnosis Mild Mental Retardation Differential diagnosis Autism: Presence of Eye Contact, Good Social Skills, Absence of No Repitative Behaviour. Suggested interventions • Behaviour Therapy‐ To encourage the child to learn and increase his self confidence • Family Therapy‐ To increase family support to the child, telling the parents not to punish the child but in turn encouraging him to do work and complimenting him on his works to increase self confidence
Page | 44 CASE‐ V Client’s Name‐ Date‐ Registration no‐ Age‐ 21 years Gender‐ Female Address‐ Educational qualifications‐ studied till 5th standard Occupation‐ None Source of Income‐ Brother – Tikki Wala Shop Marital status‐ Divorced Clients stay with parents‐ Yes with Mother and Elder brother Stay with Spouses‐ No Siblings, how many‐ 2 Sisters and 1 elder brother Position in family‐ Youngest‐ 4th Child Anyone in family suffered from mental disorder‐ No Anyone in family suffered from physical disorder‐ Clients father chronic alcoholic died from paralytic attack Informant Relation‐ Mother and Brother Source of Referral‐ Relatives Presenting complaint (in words and as in sequence told by the client) • Paglon ki tarah rehti hai, Khud se bolti hai • Iske peeche jin padha hai History of Present Illness‐ The client was married on 8th July 2010, but she returned a week after to her parent’s family as her husband was a criminal and was put in jail. She had her divorce in 26th July 2011. Her 3rd Sibling (sister) was married in 5th december2005, and got a child after 4 years of marriage. She is very close to her jija and obeys his every wish. Also the jija (who has a shop of Bidi, cigarette) gets angry and use to
Page | 45 beat his didi also because of which her didi also now obeys whatever he says. The client was forcefully brought to the hospital for admittion, she created a fuss in the waiting section where she got on the floor and was crying very loudly in a knee elbow position. On taking the case from the mother her mother said that ‘ye apne jija ki baat itni maanti hai ki agar abhi wo phone karke bula le to bhaag ke unke pass chali jaegi’. On enquiry more about the history from the mother she told that the client was staying with her 3rd sibling (sister) after the birth of their child. There only after some time, she had injured her leg for which her sister and jija took her for treatment. As per the sister told the mother ‘ilaaz karva ke a rhe the to railway ki patri pe gir gyi thi jahan se jin iske peeche lag gya’. Since then the client started behaving abnormally, use to develop trance like states? In which she use to scream a lot, after the state it was found that her clothes use to be torn, also near her neck and chest, and she had scratch marks over her body, face, chest, after every episode. She use to scream and tell in altered voice reflecting that there is a male possessing her body and he says he is possessing her as she looks like just his wife and he needs her body and would not leave her. She got bed ridden and use to cry all time. The client’s mother on seeing the day by day deteriorating condition of the mother brought her to her own home. On some relatives consultation she was taking the client to a dargah, on way the client was speaking in altered voice and asking them not to take her to the mosque there she was made to drink some holy water and some oil was put in her ear. On returning from there client could not use her legs and walk at all, the client said in an abnormal voice that because she was taken to the mosque now the Jin had done this. Later she was taken to a pooja where before going only the client stopped talking and it was said that the jin is doing this, afraid from this the family members brought her back to home. Since then the client is at home only and getting the episodes of possessions, she is not talking else when she has an act of possession. During the time of admission in IPD she was very reluctant and doing tantrums and saying again and again to take her back. She was saying no one could treat her. No doctor could treat her. • Date of onset of illness‐ 6 months back
Page | 46 • Treatment taken‐ No medical treatment taken • Got well any time in between, duration of such period‐ No • Was there any precipitating factor at each relapse? The illness is continuing since 6 months, not got well in between but the symptoms worsen whenever any type of treatment is thought to start. • Any other treatment tried in between‐ the client had been taken to a dargah but after that client stopped using her lower limbs and after she was taken to a pooja she stopped talking, now only talks when the possession attacks comes. • Effect of treatment‐ conditioned worsened because of no proper medical treatment given. • Impact of illness on daily life‐ she is not leading a normal life, is bedridden and just lies on bed. • Cannot carry on routine work‐ the client not doing any work, just lying on the bed, the mother only looks after her, the client indicates whenever there is any urge to urine or stool and mother takes her. Has to depend on others for her care, want to lie down and take rest. Interview with family members • Relationship ‐ Mother • Educational history of client‐ studied till 5th standard • Family members (Mother, brother and sister) are very much stressed and worried about the client and want her to get ready. The financial condition of the family is also not good. • Their view point – On asking the mother she said that she suspects the 3rd sibling sister and her husband had done this to hide their some wrong work, they had done something wrong with the client and to hide that they had done made her eat something or done something. Mother strongly suspects some connection of the jija with the client’s illness as jija is not a good person. She wants to keep the daughter away from them as the sister and jija may come and tell the client not to take the treatment and the client will stop the treatment immediately.
Page | 47 • In what ways illness caused inconvenience to them‐ the brother’s and mother’s work had been affected a lot because of the client’s illness. There is financial strain due to it as they had to give their time to look after the client. Past History‐ Injury of leg – fall from stairs when in sister’s house – 6 months back Fall on railway line‐ Injury on Head and back – 6 months back Family History Father was chronic alcoholic, got a paralytic attack in 2006, and was taken to DDU and RML for treatment, died in December 2012. All others apparently well and no other family history of mental/Physical illness can be elicited. Mental status examination Presentation‐ Dressed in clothes as per the season hair, dry, rough and uncombed, the client tored her dress after the attack in the OPD after which she was admitted. Appearance – Not interested in self and grooming Social interaction with staff and others in waiting room‐ Absent If someone accompanying and who‐ Mother, Brother and 2nd sibling (sister) Talking to himself in waiting room‐ client made a chaos in the waiting room where she got on the floor and was crying very loudly in a knee elbow position. She wasn’t moving there at all, was very stiff and wanted to go home. Pacing up/down the office floor‐ No Rapport building‐ Could not be achieved as the client didn’t want to be treated and admitted. Movement and behavior 25. Gait‐ Not Walking 26. Posture‐ Stiff lying in knee‐elbow position 27. Coordination‐ Present 28. Eye contact‐ Present 29. Facial expressions‐ Of Anger alternating with crying 30. Walking / coordination problem if any‐ Not Walking
Page | 48 Affect‐ Over reaction Mood ‐Client’s answer‐ anger alternating with crying spells Speech‐ No difficulty in speech could be elicited when the client is crying as she speaks then. Volume‐ High Rate/speed‐ Normal Length of answers‐ Neither too long nor too short Appropriateness of answers‐ Yes sometimes she answers as when we respond to what she is screaming. Else she don’t answers and is busy screaming ‘ le chalo’ ‘Le chalo yahan se’ Clarity of answers‐ yes Thought content‐ ok Hallucinations‐ Client not answering to questions Delusions‐ Client not answering to questions, No as per the mother. Dissociation‐ Client not answering to questions Obsessions‐ Client not answering to questions Thought process‐ Client not answering to questions • Irrelevant details‐ No • Repeated words phrases‐ repeating ‘le chalo’ ‘yahan se le chalo’ • Interrupted thinking‐ No • illogical connections‐ No Cognition • orientation – client is well oriented to Time/People/Place • long term memory‐ Could not be elicited • short term memory‐ Could not be elicited • ability to perform a simple arithmetic task‐ Could not be elicited • general intellectual level‐ Could not be elicited, looks average intelligence, as sometime after when we left the client she came out of her room on floor and when it was tried to take her back, she knew how to get her feet entangled in the furniture so as to resist, once the leg was freed in the next bed she again tangled her leg. • ability to name specified substances/ read / write complete sentences‐ Could not be elicited • ability to understand and perform a task‐ No • ability to draw a simple map or copy a geometrical figure‐ Could not be elicited
Page | 49 • inability to tell right left‐ Could not be elicited Judgment – Could not be elicited Insight – do you think you are ill? She says that her illness can’t be treated by any doctor Work history‐ N/A as client not working Marital history‐ Divorced from husband 4 years back and husband did not tried to contact after that, the husband was in jail, she left the husband 1 week after the marriage • Answers to be in verbal language? How was client answering? Yes sometimes • Hesitant? No • Free communication? Yes • Focusing on interview‐ No • Diverted easily distracted‐ Yes • Have the questions to be repeated no of times‐ Yes • General demeanor of client‐ lying on bed crying • Was client in hurry/ unwilling to continue interview‐ yes very much unwilling to take treatment also • Pause in certain questions; No • Cooperative ready to answer‐ No • Showing concern about his illness?‐ No Summary The client is a 21 year female, suffering from loss of sense of reality, she has been presenting with attacks as if a male spirit has possessed her body during which she screams, gets marks on her body (Face, chest), clothes gets tored. She is behaving madly and don’t want to get treated. Provisional Diagnosis Dissociative disorder Differential Diagnosis
Page | 50 • Schizophrenia – Absence of any do not have delusional explanations for the phenomena in a personified way Suggested interventions • Pharmacotherapy – To decrease clients restlessness and dissociative symptoms • Family counseling ‐ To tell them that the client’s condition is a medical disorder and needs a proper medical treatment with compliance and they should have patience and should cooperate in the treatment • Behaviour modification therapy‐ To increase positive wanted behavior and decrease unwanted behavior
Page | 51 CASE‐ VI Client’s Name‐ Date‐ Registration no‐ Age‐ 21 Years Gender‐ Male Address‐ Educational qualifications‐ Not Gone to School Marital status‐ Unmarried Clients stay with parents‐ Yes Stay with Spouses‐ N/A Siblings, how many‐ One elder brother Position in family‐ Younger brother Anyone in family suffered from mental disorder‐ No Anyone in family suffered from physical disorder‐ No Informant Relation‐ Mother Source of Referral‐ Family Presenting complaint (in words and as in sequence told by the Mother) • Dara hua hai • Teen din se soya nai • Idhar udhar dekhta rehta hai, ek dum dar jata hai History of Present Illness‐ • Onset‐ 3 days back • Treatment taken‐ In the past for seizures from Lady Hardinge Medical college • Got well any time in between, duration of such period‐ Yes with medication • Was there any precipitating factor at each relapse? The client is a known case of cerebral palsy with seizure disorder, he had gone to a wedding and was returning in the night train, it was a 24 hour journey and the door of the train was making sound all night due to which he could not sleep and was whole night
Page | 52 waking and seeing at the door. Since then after coming home he is crying, not sleeping and is afraid. • Any other treatment tried in between is taking treatment since childhood for seizures. Had undergone multiple tendon (Hamstring and Obturator) release operations for the stiffness, involuntary urination. • Effect of treatment‐ Seizures have decreased now and the client now understand things and interact with others • Impact of illness on daily life‐ Is not able to go to school or do any work on his own. Cannot carry the routine works, has to be assisted to toilet as cant stand and walk properly. Has to depend on others. Interview with family members • Relationship‐ Mother • Educational history of client‐ not gone to school • School / college‐ N/A • As per the family members the child got afraid while returning in the train. • In what ways illness caused inconvenience to them‐ the client is leading a dependent life, he needs an assistance to do things. Past History History of similar episode in 2009 Family History All Family members are apparently healthy, No History of Physical, mental or any similar illness can be elicited. Mental status examination Presentation‐ Client is of an obese built, well dressed as per the season in a wheelchair and was having increased salivation If someone accompanying and who‐ Mother and Brother Social interaction with staff and others in waiting room‐ Decreased Talking to himself in waiting room‐ No
Page | 53 Pacing up/down the office floor‐ No Rapport building‐ Rapport was tried to build by asking the basic details from the client and taking his name. If interested in self and grooming/ able to take care of self‐ Yes a little Movement and behavior 31. Gait‐ can walk only with support 32. Posture‐ sitting bending sideways in the wheelchair 33. Coordination‐ Not present 34. Eye contact‐ Not present 35. Facial expressions‐ Anxious with wrinkles on forehead and mouth drawn open 36. Walking / coordination problem if any‐ Can walk only with support Affect‐ Client was looking anxious and afraid, over reaction to stimulus Mood‐ Sad Speech‐ Slurred speech, Volume‐ high, Rate/speed‐ slow Length of answers‐ Short Appropriateness of answers‐ Yes Clarity of answers‐ Yes Thought content‐ Decreased Hallucinations‐ No Delusions‐ No Dissociation‐ No Obsessions‐ No Thought process‐ Diminished Cognition • Orientation – Oriented to people and place • Long term memory‐ Intact • Short term memory‐ Intact • Ability to perform a simple arithmetic task‐ Can’t be done • General intellectual level‐ Subnormal • Ability to think abstractly‐ No • Ability to name specified substances/ read / write complete sentences‐ No, can’t write • Ability to understand and perform a task‐ only tasks which can be done sitting and not involving high intellect
Page | 54 • Ability to draw a simple map or copy a geometrical figure‐ No, grasping not there, can’t hold pen, pencil • Inability to tell right left‐ No Judgment – Not present Insight – Not Present • Answers to be in verbal language? How was client answering? Yes • Hesitant? No • Free communication? No as client can’t speak properly • Evading any answer? No • Focusing on interview ‐ No , client was anxious and looking here and there • Diverted easily distracted‐ Yes • Have the questions to be repeated no of times‐ Yes • General demeanor of client‐ Sitting in wheelchair, anxious, bending on left side, Mouth open • Was client in hurry/ unwilling to continue interview‐ No • Pause in certain questions‐ No • Cooperative ready to answer‐ Yes • Showing concern about his illness? No Work History‐ None Marital History‐ Not Applicable as unmarried Summary The client is a 21 year old male child presenting with fear and anxiety since returning from a 24 hour train journey in a train. As per the informant the journey was in the night and the door of the train cabin was loose and making a lot of noise the whole night due to which the patien could not sleep and since then he is very afraid, not speaking and interacting as before.
Page | 55 Provisional Diagnosis Cerebral Palsy with Phobia Differential diagnosis Autism – Autism is not present as the client has good social skills and responsive behavious, no history of repitative bahviour could be elicited. Suggested interventions • Pharmacotherapy – To decrease anxiety • Family therapy ‐ To increase family support and Interaction • Speech therapy – To make speech more clear • Occupational Therapy‐ For managing cerebral palsy so that client can engage in some work and do something creative.
Page | 57 • Got well any time in between, duration of such period‐ No • Was there any precipitating factor at each relapse? Nothing could be elicited by clients history • Effect of treatment‐ with the previous treatment she had increased somnolence. • Impact of illness on daily life‐ she is not able to take care of herself, keep hygiene properly because of which the mother also cut her hairs short as she could not take care of it. The client is not going to school since 1st standard • Has to take leave from work place/ school/ college‐ Yes she could not attend the school • Cannot carry on routine work‐ Yes • Has to depend on others for everything‐ No • Want to lie down and take rest‐ Yes • Don’t want to do anything‐ Yes Interview with family members‐ • Relationship‐ Mother • Educational history of client‐ studied till 1st standard • How is academic performance ‐ Was not good in studies • Does client matches parents and teachers expectations‐ No • Their view point‐ she is mad. On talking with the mother it was noted that she had many bruises and injury on her body, when asked she told it’s all because of the client. The client come s suddenly from behind when the mother is resting or doing some work and tightly holds her, bites her and then go away after biting. Client is disruptive, Moody, doesn’t obey anything, does whatever she want to do, goes out to roam, wander on streets, bring things from street vendors without paying for it • In what ways illness caused inconvenience to them‐ the child is causing distress to the mother as she has to take care of her whole time and also the client bites her because of which there were many injuries over the body.
Page | 58 Family History: The client’s cousin had similar symptoms Mental status examination Presentation‐ Dressed like a boy in trouser and shirt and boy cut hairs Personal appearance‐ Neat, Well dressed as per the season, thin and tall female If interested in self and grooming/ able to take care of self‐ Yes Social interaction with staff and others in waiting room‐ No interaction with others. If someone accompanying and who‐ Mother Talking to himself in waiting room‐ Yes, screaming “ Bhagwann” “ Bhagwaan” while waiting and then laughing inappropriately. Singing songs changing it and inducing words like pagal in the song Pacing up/down the office floor‐ Sits for sometime, then goes out of the room then comes back Rapport building‐ Could not be achieved, Client not cooperative Movement and behavior 37. Gait‐ Nothing abnormal detected 38. Posture‐ Nothing abnormal detected 39. Coordination‐ Nothing abnormal detected 40. Eye contact‐ Present 41. Facial expressions‐ Notorious, smiling, as if will do something mischievous 42. Walking / coordination problem if any‐ No Affect‐ Over reaction, shouting words. Mood ‐clients answer‐ Elevated Speech‐ loud speech, High Volume, normal Rate, Length of answers‐ Unco‐operative client Appropriateness of answers‐ Unco‐operative client Clarity of answers‐ Unco‐operative client Thought content‐ Unco‐operative client, singing songs including god and abusive language Hallucinations‐ Unco‐operative client Delusions‐ Absent Dissociation‐ Absent Obsessions‐ Nothing as such
Page | 59 Thought process • Irrelevant details – answers inappropriately, singing inappropriately, Shouting “pagal” word again and again and singing bhagwaan bhagwaan and including the word pagal in the songs also. laughing inappropriately • Repeated words phrases‐ repeating work pagal and Bhagwann with herself Cognition • Orientation‐ Oriented to place, people and time. • Long term memory‐ Cant be elicited as client not answering • Short term memory‐ Cant be elicited as client not answering • Ability to perform a simple arithmetic task‐ Cant be elicited as client not answering and following commands • General intellectual level‐ Cant be elicited as client not answering and following commands • Ability to name specified substances/ read / write complete sentences‐ Cant be elicited as client not answering and following commands • Ability to understand and perform a task‐ ‐ Cant be elicited as client not answering and following commands • Ability to draw a simple map or copy a geometrical figure‐ Cant be elicited as client not answering and following commands • Inability to tell right left‐ Can’t be elicited as client not answering and following commands, but mother says no. Judgment‐ Can’t be elicited as client not answering Insight‐ Client not answering questions but herself laughing and repeating words Marital history‐ Not applicable as Unmarried Work History‐ None Summary The client is a 13 years girl, having psychotic symptoms like hallucinations, screaming, biting, singing abusive songs.
Page | 60 Provisional Diagnosis Psychotic Disorder Differential diagnosis Attention deficit hyperactivity disorder: Presence of Hallucinations, Child out of touch with reality. Eccentricities of behavior, Lack of social friends Suggested interventions • Pharmacotherapy‐ To reduce violent tendencies and aggressiveness. • Behaviour therapy – To increase positive behavior and decrease unwanted behavior. • Family therapy – To increase family support and help family to cope up with the problems faced due to the child’s illness
Page | 62 • Date of onset of illness ‐ since birth • Treatment taken‐ taking allopathic treatment since 9 months of age. • Got well any time in between, duration of such period ‐ No, is relieved by taking treatment but not total well. • Was there any precipitating factor at each relapse? The condition is continuous. The mother was very stressed mentally as well as physically due to father being a alcoholic and as she had severe cough which wasn’t getting controlled, before Raghav in previous pregnancies the client had hypertension and also had 2 spontaneous abortion at 2 and 3 months of gestation in 1st and 2nd gestation. • Any other treatment tried in between‐ Ayurvedic treatment taken for a week but after a week he developed diarrhea so treatment withdrawn. • Effect of treatment‐ Seizures stopped with allopathic medicines, is now less violent and less tendency to head banging and self biting • Impact of illness on daily life‐ The client is not able to take care of self, can’t eat food and go to toilet on his own. Has to depend on others for everything. • Has to take leave from work place/ school/ college‐ Not gone school anytime Interview with family members • Relationship ‐ Mother and Father • As the client was unable to talk information was elicited from the parents (especially mother) • In what ways illness caused inconvenience to them‐ Mother is concerned as the child is not well and they have to look after the child as he is not able to do anything and the mother has to be with him and take care of him all time. • Educational history of client – Client not gone to school • School / College ‐ Not Applicable • How is academic performance ‐ Not Applicable • Does client matches parents and teachers expectations ‐ Not Applicable • How has the performance been over years? – Not Applicable
Page | 63 • Any sudden deterioration in performance – Inability to perform simple tasks like eating, going to toilet. • Any complaints received‐ Not Applicable • Has they done anything so far to correct it? What? – Taking allopathic treatment since 9 months of age. • Any improvement with their efforts? – Decrease in anger and irritability, biting. • When did they decide to consult a mental health specialist? – Since 9 months of age when complaint wasn’t getting relieved on its own. Mental status examination Presentation‐ The client was well dressed, drowsy lean child, with Hyper‐ pigmented scar marks over dorsum of both hands and arms. Was dressed neatly, maintaining the hygiene, dressed according to season appropriate. Due to increased salivation, the saliva was dribbling through mouth which had to be cleaned by the attendant. Semi conscious state, due to the effect of allopathic medication. Personal grooming‐ Well groomed Hygiene‐ Well maintained If client dressed according to season appropriate‐ Yes If interested in self and grooming/ able to take care of self ‐ No Social interaction with staff and others in waiting room‐ Bad, no interaction could be there. If someone accompanying and who‐ Accompanied by mother and father Talking to himself in waiting room‐ No Pacing up/down the office floor‐ No Rapport building‐ Rapport can’t be established Movement and behavior 43. Gait – Can’t walk without support 44. Posture – Reclining on one side of chair as client is semi conscious 45. Coordination‐ Nothing abnormal detected 46. Eye contact‐ Absent as semi conscious 47. Facial expressions ‐ Nothing abnormal detected 48. Walking / coordination problem if any‐ Can stand and walk with support. Affect‐ Lack of response
Page | 64 Mood‐ Sleepy, somnolent. Speech – Absent, not attained. Volume ‐ Not Applicable Rate/speed ‐ Not Applicable Length of answers ‐ Not Applicable Appropriateness of answers ‐ Not Applicable Clarity of answers ‐ Not Applicable Thought content ‐ Not Applicable Hallucinations ‐ No Delusions ‐ No Dissociation ‐ No Obsessions ‐ No Cognition • Orientation – Can’t be elicited • Long term memory – Can’t be elicited • Short term memory – Can’t be elicited • Ability to perform a simple arithmetic task – Can’t be elicited • General intellectual level ‐ Subnormal • Ability to think abstractly ‐ Absent • Ability to name specified substances/ read / write complete sentences ‐ Absent • Ability to understand and perform a task ‐ Absent • Ability to draw a simple map or copy a geometrical figure ‐ Absent • Inability to tell right left‐ Absent Judgment – Absent Insight – Can’t be elicited Summary The client is a 9 year Male child staying with parents and having seizure disorder and mental retardation with tendency to self biting. Provisional diagnosis Pervasive Development Disorder with Mental retardation with self biting tendency.
Page | 65 Differential diagnosis Cerebral palsy‐ Normal EEG. No symptoms of Motor Disorder. Suggested interventions • Pharmacotherapy‐ To control seizures, anger and self biting tendency • Family therapy‐ Family therapy is generally initiated because of the symptomatic of dysfunction within the family system as a whole. The therapist focuses on the interaction between family members, analyzing the role played by each member in maintaining the system. Family therapy can be especially helpful in this case to make the environment at home more congenial, and treatment of father for alcoholism.
Page | 66 CASE‐ IX Client’s Name‐ Date Age/ Sex‐ 42 years / Male Address‐ Educational qualifications‐ BA Graduate Occupation‐ Presently not employed (Private Job 2 years before) Income‐ Not working at present Marital status‐ Married Clients stay with parents‐ Yes Stay with Spouses‐ Yes Siblings, how many‐ Three sisters Position in family‐ Eldest Child Anyone in family suffered from mental disorder‐ No Anyone in family suffered from physical disorder‐ Mother had a history of convulsions because of raised Blood sugar, son is having autism with seizure disorder, Daughter is having Haemangioma over forhead. Informant Relation‐ Wife Source of Referral – Brought by wife Presenting complaint (As per Informant) • Sharaab Peete hain • Bethe bethe baat karte rehenge • Chehre parr haath karte rahenge • Gusse mein bolte hain khud se, khud bol rhe the ‘bolte a rha tha’ • Guusa karte hain, Sunte nai h Presenting complaint (As per Client) Accident ho gya the tab se per mein pain hai, dard hota hai, zyada kaam nai kar sakte.
Page | 67 History of Present Illness‐ Client is a chronic alcoholic since more than 10 years, because of which there were many tensions at home from the beginning of marriage. Conditions worsened 2 years back when the client (intoxicated) was trying to get on a DTC bus and the driver closed the door of buss because of which the person fell and his right foot got severely crushed under the buss. The client had a plastic surgery immediately for this. But since then he is complaining of pain in the affected feet. He has not joined back his job and is now resting at home and says he can’t walk and there is pain in leg after walking for 10‐15 minutes. He still hasn’t quitted alcohol and drinks it whenever he gets money. He has also done a case against the government for negligence. Both the client and his wife aren’t working and their child is having disability (Seizures and mental retardation), there are financial constraints at home. The client’s father is the sole working member of the family. Client is reserved doesn’t share his thoughts with others. Get angered at slight things like when something is not kept at its proper place or when he is interrupted while doing some work. Gets involved in quarrels and is always saying things in anger. Saying things when walking in anger on roads. Sleep is sound sleeping in afternoon for 2‐2 ½ hour and in night from 12 to 8o’clock in morning • Date of onset of illness‐ Alcoholic since 12 years. • Treatment taken‐ No treatment taken • Was there any precipitating factor at each relapse? Increased alcoholism after the accident. • Impact of illness on daily life‐ Had left the job after the accident • Doesn’t want to do a job is looking for the case to get finished which he has done for negligence. • Cannot carry on routine work‐ No, can do routine work, but can’t walk continuously for more than 10 minutes. • Has to take leave from work place/ school/ college‐ Yes • Has to depend on others for everything‐ No
Page | 68 Interview with wife • Their view point‐ The wife is very much concerned about the husband’s alcoholism and anger. She wants him to leave alcohol. • In what ways illness caused inconvenience to them‐ The fathers alcoholism has lead to financial constraints at home, whatever money he gets anytime he goes to buy alcohol and the wife is very concerned with this as their child is very small (9 years) and have seizure and is mentally retarded. Educational history of client‐ BA Graduate Mental status examination Presentation‐ Middle Aged client, Mesomorphic Built, Well groomed and dressed as per the season, Hygiene maintained, Well dressed, with a saffron tilak on forehead. If interested in self and grooming/ able to take care of self‐ Yes Social interaction with staff and others in waiting room‐ Nothing abnormal detected If someone accompanying and who‐ Wife Talking to himself in waiting room‐ No Pacing up/down the office floor‐ No Rapport building‐ Rapport was build by making the client sit comfortably and engaging him in general conversation about his complaints. Movement and behavior 1. Gait‐ Nothing abnormal detected, walking normally, no sign of limping or pain could be objectively seen. 2. Posture‐ Nothing abnormal detected 3. Coordination‐ Nothing abnormal detected 4. Eye contact‐ Lost in between 5. Facial expressions‐ Client having facial tics as blinking of the left eye and restricted movements on right side of the face. 6. Walking / coordination problem if any‐ Nothing abnormal detected Affect‐ normal, happy, nothing abnormal detected Mood ‐ Normal
Page | 69 Speech‐ Normal, No difficulty in speech noted Volume‐ Moderate, Nothing abnormal detected Rate/speed‐ Nothing abnormal detected Length of answers‐ Appropriate Appropriateness of answers‐ Yes Clarity of answers‐ Clear Thought content‐ Clear Hallucinations‐ No Delusions‐ No Dissociation‐ No Obsessions‐ No Thought process‐ Normal thoughts of day to day events, no intrusive thoughts Cognition • Orientation ‐ Well oriented to time, people and place • Long term memory‐ Intact • Short term memory‐ Intact • Ability to perform a simple arithmetic task‐ Yes • General intellectual level‐ Average • Ability to name specified substances/ read / writes complete sentences‐ Yes • Ability to understand and perform a task‐ Yes • Ability to draw a simple map or copy a geometrical figure‐ Yes • Inability to tell right left‐ Yes Judgment – Intact Insight – Yes, Present on questioning specifically Work history • Occupation‐ Left job 2 years back after foot accident • Regular on work? No • Any complains of workplace? What? ‐ No complaints • Any leaves? How long? Not gone since 2 years • Anytime reluctant to go to office? ‐ Yes, after the accident • When was the time when client was reluctant? ‐ After the accident
Page | 70 • Reasons given by client for not attending work? ‐ Foot accident • Any complaint of performance? ‐ No • Client relationship with people in workplace ‐ Good • Boss‐ Ok • Colleagues‐ Ok • Subordinates‐ Ok • Anyone bothering at workplace‐ No Marital history • Day to day dealings‐ Present, does day to day work • Sex life‐ No complaints • Work relationship (spouse is working if)‐ No • Relationship with children‐ Good, close to children • Relationship with opposite sex‐ Ok • Decision making‐ Present • Sharing of work at home‐ Yes • Relationship with spouse’s relatives‐ Normal relationship • Relationship with spouse’s friends‐ Normal relationship • Answers to be in verbal language? How was client answering? Yes • Hesitant? No • Free communication? Yes • Evading any answer? He wasn’t telling about his alcoholic tendency till it was asked specifically, and wasn’t guilty about the same, said there is nothing wrong in drinking alcohol. • Focusing on interview‐ Yes • Diverted easily distracted‐ No • Have the questions to be repeated no of times‐ No • General demeanor of client‐ Cooperative • Was client in hurry/ unwilling to continue interview‐ No • Pause in certain questions‐ No • Cooperative ready to answer‐ Yes • Showing concern about his illness? Yes
Page | 71 Summary The client is a is a 42 year old male having chronic history of alcoholism and anger problems. The client had suffered an accident 2 years back of foot after which he has stopped working and is now not doing any home. The clients son is suffering from autism and seizure disorder and the clients alcoholism and not going to any job has lead to financial constraints on the whole family. Also whatever money the client gets he spends in buying alcohol with which the clients wife is very much concerned. Provisional Diagnosis Chronic Alcohol abuse Differential diagnosis • Depressive disorders: Absence of sad, empty, or irritable mood, ccompanied by somatic and cognitive changes that significantly affect the individualʹs capacity to function. • Post traumatic stress disorder: Absence of any recurrent intrusive thoughts about any traumatic event, dissociative reactions, flashblacks, avoidance to any stimuli associated with any traumatic event. Suggested interventions • Pharmacotherapy ‐ For Anger and Mood stabilization • Cognitive behavior therapy‐ To increase cognitive attitudes toward responsibility for oneʹs behavior and Decrease alcoholism • Motivational interviewing therapy—A person‐centered therapy that relies on a client’s inspiration to change and motivating the same. • Family therapy‐ To increase family support and Interaction • Deep Relaxation therapy‐ by including breathing exercises, focused muscle tensing and progressive muscle relaxation techniques to decrease anxiety and for anger management.
Page | 72 CASE‐ X Client’s Name‐ Date‐ Age‐ 45 years Gender‐ Female Address‐ Educational qualifications‐ 8th Pass Occupation‐ Housewife Marital status‐ Married Clients stay with parents‐ No Stay with Spouses‐ Yes Family‐ three sons and 3 daughters, living with husband, Position in family‐ eldest/youngest/ middle/only child Anyone in family suffered from mental disorder‐ No Anyone in family suffered from physical disorder‐ Informant Relation‐ Daughter Source of Referral‐ Self Presenting complaint (in words and as in sequence told by the client) • Pain in neck • Dill chalta hai • Wajan badta nai hai • So ke uthungi to mann fresh nai lagta • Pet mein dard hai • Badan mein dard hai Presenting complaint (in words and as in sequence told by the Informant) • Roti rehti hain • Sir aur Badan dard batati hai • Khana theek se nai khati
Page | 73 History of Present Illness‐ • The client was apparently well 3 months back when her son stole some 20,000 rupee from home and ran away, husband was very angry with this and got into argument with the wife and beat her on the head, chest and pushed her on the floor. He had bleeding from left ear that day. Client was taken to a government hospital and investigated and sent back home. Since then she had pain in neck, unable to move it downwards, pain in left ear, find it difficult to stand from sitting position. She also complained of Mann udass rehta hai, Kuch karne ka mann nai karta, Neend nai ati, Jaldi thak jati hun, Zindagi bekar lagti hai Client’s Weight‐ 40 Kg • Onset‐ Insidious • Precipitating factor at each relapse‐ Quarrel and fight with the husband, after the husband had beaten her. • Any other treatment tried in between‐ No • Impact of illness on daily life‐ She can’t live normally, is sad. Interview with family members • Relationship‐ Daughter • Educational history of client‐ studied till 8th standard • Their view point‐ the complaints started after father has beaten her after brother left the house. • In what ways illness caused inconvenience to them‐ No inconvenience as such, she is concerned about the health of the mother. Past History‐ Nothing Significant Family History Father is a chronic alcoholic Daughter is taking psychiatric treatment
Page | 74 Mental status examination (except in coma and unconscious clients/client with unknown language) Presentation‐ lean thin female, haphazardly dressed, hair not well groomed, looking very anxious, dressed as per the season. Hygiene ok. Social interaction with staff and others in waiting room‐ yes, Present If someone accompanying and who‐ Daughter Talking to himself in waiting room‐ No Pacing up/down the office floor‐ No Rapport building‐ Rapport was build by asking the client to sit comfortably, and asking her to relax and tell her complaints. Appearance – if interested in self and grooming/ able to take care of self‐ No Movement and behavior 49. Gait‐ Nothing abnormal detected 50. Posture‐ straight and erect, alert. 51. Coordination‐ Present 52. Eye contact‐ Present 53. Facial expressions‐ Anxious 54. Walking / coordination problem if any‐ No Affect‐ Over reaction while explaining about her pains and complaints Mood‐ Sad but highly anxious Speech‐ Fluent and sharp voice Volume‐ High Rate/speed‐ Little fast Length of answers‐ Long Appropriateness of answers‐ Yes Clarity of answers‐ Yes Thought content‐ No abnormal intrusive thoughts Hallucinations‐ No Delusions‐ No Dissociation‐ No Obsessions‐ No Thought process‐ No Irrelevant details, repeated words phrases, interrupted thinking or illogical connections Cognition • Orientation –Well Oriented to Time/People and Place
Page | 75 • long term memory‐ Intact • short term memory‐ Intact • ability to perform a simple arithmetic task‐ Yes • general intellectual level‐ Average • ability to name specified substances/ read / write complete sentences‐ Yes • ability to understand and perform a task‐ Yes • ability to draw a simple map or copy a geometrical figure‐ Yes • inability to tell right left‐ Yes Judgment – ask commonsense problem (as running out of a prescription medicine, or find a sealed envelope on floor)‐ Intact Insight – do you think you are ill? Intact Work history‐ None as Housewife Marital history • Day to day dealings‐ Little turmoil as Husband is alcoholic and gets angry and beats her • Sex life‐ Ok • Work relationship (spouse is working if)‐ N/A as female is Housewife • Relationship with children‐ Good • Relationship with opposite sex‐ Ok • Decision making‐ Present • Sharing of work at home‐ Yes • Relationship with spouse’s relatives‐ Ok • Relationship with spouse’s friends‐ Ok • Answers to be in verbal language? How was client answering? Yes • Hesitant? No • Free communication? Yes • Evading any answer? No • Focusing on interview‐ Yes • Diverted easily distracted‐ No • Have the questions to be repeated no of times‐ No
Page | 76 • General demeanor of client‐ very anxious client, when asked to be seated and some other client was in discussion she seated very carefully and erect spine and was totally quiet for a while • Was client in hurry/ unwilling to continue interview‐ No • Pause in certain questions‐ No • Cooperative ready to answer‐ Yes • Showing concern about his illness?‐ Yes, very much Summary The client is a 45 year old lady, who has got in a fight with the husband and the husband beat her. She is since then complaining of bodyache, Headache, weakness, not eating food and very anxious. Provisional Diagnosis Somatoform disorder Differential diagnosis • Anxiety Disorder – Ruled out due to presence of excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns, Undue concern about somatic symptoms • Post traumatic stress disorder: Absence of any trauma, or any recurrent intrusive thoughts about any traumatic event, dissociative reactions, flashblacks, avoidance to any stimuli associated with any traumatic event. Suggested interventions The client has been admitted in the In Clients department. • Pharmacotherapy – To Decrease anxiety and restlessness. • Other investigations‐ Referred to an orthopedic, Neurologist and surgeon for eliciting any deep injuries. • Deep Relaxation therapy‐ Including breathing exercises, focused muscle tensing and progressive muscle relaxation techniques to decrease anxiety and provide mental relaxation. A session of
Page | 77 Progressive muscle relation therapy was done with the client. By asking her to close her eyes and try to relax the mind. She was asked to take deep breaths. She was then asked to focus all her attention on the left foot and to tighten it as much as possible, then she was asked to relax it and similarly she was one by one asked to focus on different parts of the whole body. After the session she feels little more at ease and relaxed than before. She was asked to do the same exercise before sleeping at night. • Family therapy‐ Treatment of the husband for anger management and alcoholism is to be done he has been asked to come next time.
Page | 78 DISCUSSION The internship had been a learning experience providing an opportunity to integrate theoretical knowledge, and clinical skills into practice. The training goal was to help acquire skills in clinical psychology and professional acumen under trained practitioners in the concerned setting, which was achieved. Strategies were planed and assessed during the internship helping clients and clients from different settings to overcome the problems. Also it had been a learning experience to deal with diverse population including children, adolescents and adults and learning to conduct tests and assessments making proper interpretations of the results emerging from the testing. Ten cases with case history, Mental Status Examination alongwith suggested intervensions are mentioned which were handled during the internship.
Page | 79 REFERENCES ƒ American Psychiatric Association., & American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders‐ DSM‐IV‐TR. American Psychiatric Association. ƒ American Psychiatric Association., & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders‐ DSM‐5. American Psychiatric Association ƒ Semple, David; Smyth, Roger; Burns, Jonathan; Darjee, Rajan; McIntosh, Andrew (2005), Oxford Handbook of Psychiatry, 1st Edition ƒ Kaplan, H. I., Sadock, B. J., Grebb, J. A.,(1994). Kaplan and Sadockʹs synopsis of psychiatry‐ Behavorial sciences, clinical psychiatry. 7th Edition, Baltimore‐ Williams & Wilkins ƒ Sadock, Benjamin James; Sadock, Virginia Alcott (2007), Kaplan & Sadockʹs Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition, Lippincott Williams & Wilkins ƒ Strickland, B. B. (2001). The Gale Encyclopedia of Psychology. Farminton Hills, MI‐ Gale Group.

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IGNOU Sample Internship File for MPCE015 GW

  • 1.
    REPORT OF INTERNSHIP At LADYHARDINGE MEDICAL COLLEGE Presented to THE FACULTY OF THE DISCIPLINE OF PSYCHOLOGY, School of Social Sciences, IGNOU In partial fulfillment of the requirements for the degree of M.A. PSYCHOLOGY ADVISORS‐ MR. BY Enrolment no.
  • 2.
    Page | 2 ACKNOWLEDGEMENT Thisinternship would not have been possible without the kind support and help of my Seniors and Colleagues and I would like to extend my sincere thanks to all of them. I am highly indebted to for their valuable guidance and constant supervision during my internship at Lady Hardinge medical college. I would like to express my gratitude towards my Teacher for their constant motivation and guidance.
  • 11.
    Page | 11 CONTENTS INTRODUCTION.............................................................................................12 HISTORY OF THE INSTITUTION.................................................................12 SAMPLE CASE FORMAT ...............................................................................14 CASE‐ I..............................................................................................................20 CASE‐ II.............................................................................................................27 CASE‐ III............................................................................................................34 CASE‐ IV............................................................................................................39 CASE‐ V.............................................................................................................44 CASE‐ VI............................................................................................................51 CASE‐ VII...........................................................................................................56 CASE‐ VIII..........................................................................................................61 CASE‐ IX............................................................................................................66 CASE‐ X.............................................................................................................72 DISCUSSION.....................................................................................................78 REFERENCES....................................................................................................79
  • 12.
    Page | 12 INTRODUCTION Internshipis an important component of the MA Psychology Programme of IGNOU. This internship was carried out for a period of 240 hours under the constant supervision of , Director, Professor Head and Consultant Child Psychiatrist, Psychiatry Service for Children, Adolescent & Adults and De‐addiction Centre, in Lady Hardinge Medical College, New Delhi‐110001. OBJECTIVES OF INTERNSHIP ƒ To provide comprehensive training in field of psychology. ƒ To help develop skills and techniques to provide the needed services to individuals, groups and organizations as a psychologist. ƒ To develop professional competence as a psychologist. ƒ To encourage the learner to maintain the highest standards in offering the psychological services. SELECTION OF AGENCY FOR INTERNSHIP The psychiatric department of Lady Hardinge Medical College, a renowned medical college, was chosen for pursuing internship. HISTORY OF THE INSTITUTION The Lady Hardinge Medical College, a pioneer in the field of Medical Education has the unique distinction of being the only Medical College in India, for exclusively training women undergraduate students. The college was founded by Lady Hardinge of Penhurst, the wife of the Viceroy of India, in order to overcome the orthodox trends prevailing the contemporary India, amongst the parents’ minds against educating their daughters in co‐educational Colleges. She used her good offices to raise funds from the Princely States & the Public. The Institution was formally opened by Lord Hardinge in February 1916. The doctors who have tread the paths of this college have achieved fame worldwide. They have risen to key positions and outshone in their respective fields, like Dr. Sushil Nayar, Dr. Usha Luthra of I.C M.R., Dr. Sumedha Khanna of W.H.O. Dr. Saroj Pachauri of Ford Foundation. The College started under the able leadership of Dr. Kate Platt M.D, who was the first Principal of the College. At present the Director of the college
  • 13.
    Page | 13 isDr. G.K. Sharma. The College has coma long way, retaining its unique character, still marching ahead with the times and is upgrading itself dynamically in all its fields of activities. Since its inception, the institution has produced 6125 graduates and 2564 postgraduates in various medical and surgical specialities. The students and faculty have constantly strived for academic excellence, state‐of‐the‐ art health care provision, and high quality research competing with the best in the country. For the teaching and training of medical students, the college has two full fledge hospitals‐ Smt. Sucheta Kriplani Hospital, and Kalawati Saran Child Hospital with bed strength of 877 and 350 respectively. All the department of the hospitals are equipped with modern facilities to provide tertiary level health care services to the people of Delhi & adjoining areas. Since 1991 the hospital has been providing care to the male clients also. The Psychiatric Department is headed by , Director, Professor Head and Consultant Child Psychiatrist, Psychiatry Service for Children, Adolescent & Adults and De‐addiction Centre. BRIEF DESCRIPTION OF THE INTERNSHIP Internship under , Department of psychology, was started from The internship included taking whole case history of the patient as far as can be elicited with an aim to arrive at the most probable causation and diagnosis of the disorder. The cases taken by the interns were then described to the agency supervisor for further suggestive investigations, pharmacological and therapeutic interventions.
  • 14.
    Page | 14 SAMPLECASE FORMAT Client’s Name‐ Date Registration no‐ Age‐ Gender‐ Address‐ Educational qualifications‐ Occupation‐ Income‐ Marital status‐ Clients stay with parents‐ Stay with Spouses‐ Siblings, how many Position in family‐ eldest/youngest/ middle/only child Anyone in family suffered from mental disorder Anyone in family suffered from physical disorder Informant • Relation‐ • Source of Referral‐ Presenting complaint (in words and as in sequence told by the client) History of Present Illness‐ • Onset‐ • Treatment taken‐ • Got well any time in between, duration of such period • Was there any precipitating factor at each relapse? • How many relapse • Any other treatment tried in between‐ • Effect of treatment‐ • Impact of illness on daily life‐ • Has to take leave from work place/ school/ college‐ • Cannot carry on routine work‐
  • 15.
    Page | 15 •Has to depend on others for everything‐ • Want to lie down and take rest‐ • Don’t want to do anything‐ • Others Interview with family members • Relationship‐ • Their view point‐ • In what ways illness caused inconvenience to them‐ • Educational history of client‐ • School / college‐ • How is academic performance‐ • Does client matches parents and teachers expectations‐ • How has the performance been over years? • Any sudden deterioration in performance • Any complaints received • Has they done anything so far to correct it? What? Past History Family History Mental status examination (except in coma and unconscious clients/client with unknown language) Presentation Personal appearance Social interaction with staff and others in waiting room If someone accompanying and who Personal grooming Hygiene‐ If client dressed according to season appropriate Talking to himself in waiting room Pacing up/down the office floor Rapport building Appearance – if interested in self and grooming/ able to take care of self Movement and behavior
  • 16.
    Page | 16 1.Gait 2. Posture 3. Coordination 4. Eye contact 5. Facial expressions 6. Walking / coordination problem if any Affect Over reaction / lack of response Mood ‐clients answer‐ sad/ happy/ angry Speech Volume Rate/speed Length of answers Appropriateness of answers Clarity of answers Thought content Hallucinations • Do you hear some voices telling you something to do? • Do you hear some voices when no one present? • Do you feel someone is talking about you and loudly saying whatever u doing Delusions • Do you feel people are after you? • Do you sometimes feel people are talking about you? • Do you sometimes feel your phone is tapped • Do you feel people are overhearing your conversation? Dissociation • What is your name • Who are you? • What work you do? • Do you sometimes feel that you don’t know who you are? Obsessions‐ • Any particular thought come into your mind again and again? • Sometimes a strange idea or feeling comes in your mind, which is not correct and how much you try the though don’t go off • Any impulse to clean, wash hands, locks on doors repeated
  • 17.
    Page | 17 Thoughtprocess • Irrelevant details • Repeated words phrases • Interrupted thinking • illogical connections Cognition • Orientation – T/P/P • Long term memory • Short term memory • Ability to perform a simple arithmetic task • General intellectual level • Ability to think abstractly • Ability to name specified substances/ read / write complete sentences • Ability to understand and perform a task • Ability to draw a simple map or copy a geometrical figure • Inability to tell right left Judgment – ask commonsense problem (as running out of a prescription medicine, or find a sealed envelope on floor) Insight – do you think you are ill? • Any improvement with their efforts? • When did they decide to consult a mental health specialist? Work history • Occupation • Regular on work? • Any complains of workplace? What? • Any leaves? How long? • Anytime reluctant to go to office? • When was the time when client was reluctant? • Reasons given by client for not attending work? • Any complaint of performance? • Client relationship with people in workplace • Boss • Colleagues
  • 18.
    Page | 18 •Subordinates • Anyone bothering at workplace Marital history • Day to day dealings • Sex life • Work relationship (spouse is working if) • Relationship with children • Relationship with opposite sex • Decision making • Sharing of work at home • Relationship with spouse’s relatives • Relationship with spouse’s friends • Answers to be in verbal language? How was client answering? • Hesitant? • Free communication? • Evading any answer? • Focusing on interview • Diverted easily distracted • Have the questions to be repeated no of times • General demeanor of client • Was client in hurry/ unwilling to continue interview • Pause in certain questions • Cooperative ready to answer • Showing concern about his illness? Summary Provisional Diagnosis Differential diagnosis Suggested interventions
  • 19.
  • 21.
    Page | 21 alongwith them. The complaints started after the Elder Brother got married, a sum of 5 lac rupees was taken on Loan from a nearby Seth for the marriage. But suddenly a change in behavior of the elder brother was noted after marriage he started becoming aloof and stopped talking to the other family members. The Money lender put pressure on the family for getting his money back, but the elder brother showed no concern and quarrels started happening between the client’s father and the elder brother. The elder brother said that he won’t be giving any money and all pressure came upon the client’s father, the client’s father a alcoholic started getting more angry and everyday there were quarrels going on in the house. The client is concerned about the pressure on the father and gets scared from the fights which happen in the family. Though she was closest to the elder brother she felt much neglected as the elder brother stopped talking to her and her family properly after marriage. The client said ` wo baat nai karte, seethe upar apne kamre mein chale jaten hai, badal gaye hain’. She says ‘ab wo ghar mein paise bhi nai dete’. She says ‘bhabhi mana karti hai unhe baat karne se’, ‘bhabhi khud bhi theek se baat nai karti, ‘ladai karati hai’ When enquired about the earning members it was elicited • 1st sibling‐ the elder brother is doing Tent work. gets about 10,000 money per month. • 2nd sibling sister is married • 3rd sibling sister ‐ who use to work has also left her work and is now all day at home, • 4th sibling had joined some mobile shop, but goes on and off, so he earns only when he goes • She is the 5th child • And 6th sibling sister is in school in 12th class Gradually the client started feeling very anxious and developed palpitations. she said sone lagti hun to ghabrahat hoti hai , koi bhi awaaz a jaye to darr lagta hai. Dimaag mein khayaal ate hain har waqt’. She is thinking about how the financial condition could be stabilized how the loan could be payed. She was taking tuitions for all subjects at home since 2 months from which she could just get a meager amount of 1350/‐. She has her exams in June now and is now also tensed about her exams, she said she had to fill her fees in college for giving exams but she gave the
  • 22.
    Page | 22 moneyto papa as they wanted it. She is very much anxious with the financial constraint of the family. She is anxious about how her fees will be filled and if she will be able to give the exams and if she will pass the exams and her year is not spoiled. She says ‘mummy sunti nai hai, mein bolti hun parr wo sunti nai hai’ The client is having tension and anxiety from any sudden noise, is crying very often most of the times when alone, as she feels helpless. Her Appetite is decreased, eats one chappati, she feels angry but is unable to express it. The client hasn’t slept since 8 Days. • Onset‐ 6 months back • Treatment taken‐ No Treatment Taken • Got well any time in between, duration of such period‐ No • Was there any precipitating factor at each relapse? After the marriage of Elder Brother (Financial Problems grew and brother also became indifferent) Symptoms increase after quarrels at home • Impact of illness on daily life‐ the client is not able to concentrate on her studies, her exams is in June, but she is all time engrossed in thoughts about the financial constraint Interview with family members • Relationship‐ Mother • Educational history of client‐ Ist year student • Their view point‐ The client thinks a lot due to which she could not sleep, she hasn’t slept at all since 8 days, gets awake at night and say she is anxious • In what ways illness caused inconvenience to them‐ No inconvenience but they are concerned as the client is not well Past History‐ Nothing Significant Family History Father is a chronic alcoholic; else all family members are apparently healthy.
  • 23.
    Page | 23 Mentalstatus examination Presentation‐ Dressed in simple clothes as per season, hair groomed, hygiene maintained Personal appearance‐ Neat and Clean Social interaction with staff and others in waiting room‐ Yes. If someone accompanying and who‐ Brother and Mother Talking to himself in waiting room‐ No, Sitting quietly Pacing up/down the office floor‐ No Rapport building‐ rapport was build by asking to sit comfortably and relax. After the client was seated comfortably she was asked as per what is the problem empathetically. Appearance – if interested in self and grooming/ able to take care of self‐ Yes Movement and behavior 7. Gait‐ Nothing abnormal detected 8. Posture‐ Nothing abnormal detected 9. Coordination‐ Present 10. Eye contact‐ Present 11. Facial expressions‐ Sad, anxious 12. Walking / coordination problem if any‐ No Affect‐ Decreased response to whatever happening in the room Mood ‐clients answer‐ Sad Speech‐ Normal, no difficulty noted Volume‐ Slow Rate/speed‐ slow Length of answers‐ neither too short nor too long. Appropriateness of answers‐ Yes Clarity of answers‐ Yes Thought content‐ Positive Hallucinations‐ No Delusions‐ No Dissociation‐ No Obsessions‐ No Thought process‐ No Irrelevant details, repeated words phrases, interrupted thinking or illogical connections. Clear thought. But interrupted thoughts due to concern about the family financial condition.
  • 24.
    Page | 24 Cognition •Orientation – Well Oriented to Time/People and Place • long term memory‐ Intact • short term memory‐ Intact • ability to perform a simple arithmetic task‐ Yes • general intellectual level‐ Average • ability to think abstractly‐ Yes • ability to name specified substances/ read / write complete sentences‐ Yes • ability to understand and perform a task‐ Yes • ability to draw a simple map or copy a geometrical figure‐ Yes • inability to tell right left‐ Yes Judgment – ask commonsense problem (as running out of a prescription medicine, or find a sealed envelope on floor)‐ Yes Insight – do you think you are ill‐ Yes Work history • Occupation‐ Taking tuitions for all subjects since 2 months • Regular on work? Yes • Any complains of workplace? What? She can’t concentrate on teaching children • Any leaves? How long? Yes , she is sometimes asking students to come later, but she can’t do it always, as they will then stop the tuitions , so the client is concerned • Anytime reluctant to go to work? Yes, as she can’t concentrate and also she have to study for her exams also • When was the time when client was reluctant? Yesterday • Reasons given by client for not attending work? she can’t concentrate and also she have to study for her exams also • Any complaint of performance? No • Client relationship with people in workplace‐ Ok • Anyone bothering at workplace No Marital history‐ Unmarried • Answers to be in verbal language? How was client answering? Yes • Hesitant? No
  • 25.
    Page | 25 •Free communication? Yes • Evading any answer? No • Focusing on interview‐ No • Diverted easily distracted‐ No • Have the questions to be repeated no of times‐ No • General demeanor of client‐ very laid back and tired, looking dull • Was client in hurry/ unwilling to continue interview‐ No • Pause in certain questions‐ Yes occasional. • Cooperative ready to answer‐ Yes • Showing concern about his illness? Yes Summary The client is a 18 year female suffering from anxiety and palpitation since 6 months. She is sleepless and all the time thinking about the financial constraints because of which she can’t concentrate on her studies and tuition students also. The anxiety and palpitations increase after any episode of quarrel at home. Provisional Diagnosis Adjustment Disorder with Anxiety Differential diagnosis • Depressive disorders: Absence of sad, empty, or irritable mood, ccompanied by somatic and cognitive changes that significantly affect the individualʹs capacity to function. • Post traumatic stress disorder: Absence of any trauma, or any recurrent intrusive thoughts about any traumatic event, dissociative reactions, flashblacks, avoidance to any stimuli associated with any traumatic event. • Personality Disorder: Absence of lifetime history of personality functioning, vulnerability to distress, stressors may also exacerbate personality disorder symptoms. Suggested interventions • Pharmacotherapy – Mood stabilizers were prescribed.
  • 26.
    Page | 26 •Cognitive behavior therapy‐ She was asked questions to increase her cognitive thinking processes and again talked about her responsibilities and courier and talked about to increase her thinking process. She has been admitted, her mother is asked to bring her books here so she can study here only. A time table was prepared for her to follow( till she is in the In client department) so that she could effectively manage her time in studies • Deep Relaxation therapy‐ Including breathing exercises, focused muscle tensing and progressive muscle relaxation techniques to decrease anxiety and provide mental relaxation. A session of Progressive muscle relation therapy was done with the client. By asking her to close her eyes and try to relax the mind. She was asked to take deep breaths. She was then asked to focus all her attention on the left foot and to tighten it as much as possible, then she was asked to relax it and similarly she was one by one asked to focus on different parts of the whole body. After the session she feels little more at ease and relaxed than before. She was asked to do the same exercise at home before sleeping at night. Follow Up The client was admitted in In‐Client department to seclude her from the home environment. She has Slept last night after the medicine. But she is anxious and palpitations occur at night. client complains of thoughts about home coming in mind. She can’t concentrate on studies because of the thoughts. She hasn’t done the relaxation exercise in the night. She is asked to do it regularly. Sleep has improved. She is less anxious now. Is doing the relaxation exercise in night. She wants to go home and was discharged. A time table has been prepared for her so that she can manage her time in home and can spare as much time as possible for studying. She has been asked to focus on her studies only and not to think very much and leave the big decisions to elders. Her mother and brother have been asked to be supportive to her.
  • 27.
    Page | 27 CASE‐II Client’s Name‐ Date‐ Registration No‐ Age‐ 17 years Sex‐ Female Address‐ Educational qualifications‐ 1st year Student Occupation‐ None, presently 1st year Student Marital status‐ Unmarried Client stay with parents‐ Yes Stay with Spouses‐ Not Applicable Siblings, how many‐ 2 sisters and 2 brothers Position in family‐ Fourth Child Anyone in family suffered from mental disorder‐ Mother had a history of maniac symptoms and was admitted 4 years back in lady Hardinge medical hospital Anyone in family suffered from physical disorder‐ Mother undergoing treatment for arthritis and thyroid disorder. Informant Relation‐ Father Source of Referral ‐ Self Presenting complaint (As told by the informant) • Not talking • Gum sum rehti hai • No Appetite • Crying and laughing Presenting complaint (As told by the client) Client did not told any complaint so the informant was asked about what happened and history was taken from the informant, then the client was interrogated for more information.
  • 28.
    Page | 28 Historyof Present Illness‐ Client was apparently well 4 days back she was stressed and studying day and night for exams, was not sleeping properly and taking her meals properly, father concerned about the same scolded the client and slapped the client once and didn’t talked with her for 2 days, since then the client had stopped talking normally and is now less cheerful. She is eating less and only when father feeds her, having vertigo and weakness and insomnia. Premorbid behaviour‐ cheerful and talkative. The client says “I am mad” she refuses that she was scolded by her father. Client is sitting quietly in a side. • Date of onset of illness‐ 4 days back • Treatment taken‐ Nothing • Got well any time in between, duration of such period‐ No • Was there any precipitating factor at each relapse? The client was slapped and scolded by the father and also the father didn’t talked with the client for 2 days (the client was most closest to the father and the father had never scolded or talked with her in high tone) • How many relapse‐ the problem is persisting since 2 days. • Any other treatment tried in between‐ No treatment taken • Effect of treatment‐ Not Applicable • Impact of illness on daily life‐ The client had her exams coming and now her study is getting affected. • Has to take leave from work place/ school/ college‐ On a later follow up it was seen that she dint appeared for her exams • Cannot carry on routine work‐ Yes, earlier she was studying day and night for exams, not eating properly but since the incident the client is now quiet and sitting, not studying. • Has to depend on others for everything‐ No • Want to lie down and take rest‐ No • Don’t want to do anything‐ No • Others‐ She is now quiet and not talking. She is not as cheerful as before. Interview with family members • Relationship‐ Father
  • 29.
    Page | 29 •Their view point‐ On questioning the father about the most probable reason for her change of behavior the father said that it’s because of him as he dint ever scolded the child and she has got a shock after he scolded, slapped her and dint talked to her. • In what ways illness caused inconvenience to them‐ the child is now not as cheerful as before and also could not study, they are concerned if her exams and studies will get affected. • Educational history of client‐ College • School / college‐ Government Girl Senior secondary school • How is academic performance‐ Average (Getting 70% marks) • Does client matches parents and teachers expectations‐ No • How has the performance been over years? Average • Any sudden deterioration in performance‐ Yes since 4 days is not able to concentrate • Any complaints received‐ Not gone to school after the incident • Has they done anything so far to correct it? What? Brought to the hospital for treatment and consultation. • When did they decide to consult a mental health specialist? When after 2 days she wasn’t behaving normally. Family History All members are apparently well. Mother had a history of manic symptoms 4 years back (started from 6‐7 days sleeplessness, headache, laughing, talking, tearing clothes) for which treatment was taken from lady Irwin medical college, and also taking treatment for Thyroid disorder.
  • 30.
    Page | 30 Mentalstatus examination Presentation‐ The client was well dressed and groomed suitable to the occasion and season Social interaction with staff and others in waiting room‐ Very less interaction, talks only when asked something. If someone accompanying and who‐ Father Talking to himself in waiting room‐ No Pacing up/down the office floor‐ No Rapport building‐ Rapport was build with the clients by making her comfortable by politely asking her about her complaints and daily life and taking her outside for a casual walk so as to relieve her tension. After this the client seems comfortable and was smiling and happy. Appearance – if interested in self and grooming/ able to take care of self‐ Yes. Movement and behavior 1. Gait‐ Body very stiff, very stiffness seems on walking; client seemed much tensed and was not able to relax. 2. Posture‐ Stooped shoulders while walking 3. Coordination‐ Proper and intact 4. Eye contact‐ Intact 5. Facial expressions‐ Decreased facial expression 6. Walking / coordination problem if any‐ No Affect‐ Decreased, low sad mood, Blankness of face Mood ‐clients answer‐ Blank expression Speech‐ decreased Volume‐ Low Rate/speed‐ Low Length of answers‐ Short Appropriateness of answers‐ Yes Clarity of answers‐ Yes Thought content‐ Present, but slow, takes time to answer Hallucinations‐ No Delusions‐ No Dissociation‐ No Obsessions‐ No Thought process‐ Normal, no intrusive thoughts.
  • 31.
    Page | 31 Cognition •Orientation – Well oriented to Time/People/Place • Long term memory‐ Intact • Short term memory‐ Intact • Ability to perform a simple arithmetic task‐ Intact • General intellectual level‐ Intact • Ability to name specified substances/ read / write complete sentences‐ Intact • Ability to understand and perform a task‐ Intact, but slow++ • Ability to draw a simple map or copy a geometrical figure‐ Intact • Inability to tell right left‐ Intact Judgment‐ Present Insight – Do you think you are ill? Not clear Marital History: Unmarried Work History: Not Applicable as student • Answers to be in verbal language? How was client answering? Yes • Hesitant? No • Free communication? Yes • Evading any answer? No • Focusing on interview‐ Yes • Diverted easily distracted No • Have the questions to be repeated no of times? Yes sometimes • General demeanor of client‐ Lack of emotions and response • Was client in hurry/ unwilling to continue interview‐ No • Pause in certain questions‐ Yes, the client was asked to write her name in different languages she wrote in English and Hindi and when asked to write in Urdu which is also one of her subjects and in which she is getting good marks in the subject, she suddenly paused and said slowly no she don’t know how to write in Urdu. She wanted to join Zakir Husain College, ( An Urdu Medium School) but when asked to write Urdu she says she don’t know. On insisting by mother she wrote her name lastly.
  • 32.
    Page | 32 •Cooperative ready to answer‐ Yes • Showing concern about his illness? No Summary The client is a 17 year old female enrolled in 1st year of college, who was approaching exams. Due to her high expectations she was stressed a lot and busy studying day and night for exams, not sleeping or eating properly because of which father scolded and slapped by her. But since then she has developed sudden change in behavior from premorbid cheerful personality to now remaining quiet and aloof and not sleeping at all. Provisional Diagnosis Adjustment Disorder Differential Diagnosis • Depressive disorders: Absence of sad, empty, or irritable mood, ccompanied by somatic and cognitive changes that significantly affect the individualʹs capacity to function. • Post traumatic stress disorder: Absence of any recurrent intrusive thoughts about any traumatic event, dissociative reactions, flashblacks, avoidance to any stimuli associated with any traumatic event. • Personality Disorder: Absence of lifetime history of personality functioning, vulnerability to distress, stressors may also exacerbate personality disorder symptoms. Interventions Done • Pharmacotherapy – Mood stabilizers were prescribed. • Cognitive behavior therapy‐ She was asked questions to increase her cognitive thinking processes and again talked about her responsibilities and courier and talked about to increase her thinking process.
  • 33.
    Page | 33 •Deep Relaxation therapy‐ Including breathing exercises, focused muscle tensing and progressive muscle relaxation techniques to decrease anxiety and provide mental relaxation. A session of Progressive muscle relation therapy was done with the client. By asking her to close her eyes and try to relax the mind. She was asked to take deep breaths. She was then asked to focus all her attention on the left foot and to tighten it as much as possible, then she was asked to relax it and similarly she was one by one asked to focus on different parts of the whole body. After the session she feels little more at ease and relaxed than before. She was asked to do the same exercise at home before sleeping at night. Follow up The client seems better and cheerfulness has increased. The client has not given the exams and is saying she will give exams after 2 months after full preparation. She is positive and ambitious about her marks.
  • 34.
    Page | 34 CASE‐III Client’s Name‐ Date‐ Registration no‐ Age‐ 7 years Gender‐ Female Address‐ Educational qualifications‐ Not gone to school Marital status‐ Unmarried Client stay with parents‐ Yes Stay with Spouses‐ No Siblings, how many‐ 1 elder brother (11 years) and 1 sister (7 years) Position in family‐ eldest/youngest/ middle/only child‐ Younger Anyone in family suffered from mental disorder‐ No Anyone in family suffered from physical disorder‐ No Informant Relation‐ Mother Source of Referral ‐ Relatives Presenting complaint (in words and as in sequence told by the client) • Paper khati hai • Kehna nai manti • Paglon ki tarah rehti hai History of Present Illness‐ Client was a full term normal vaginal delivery, with birth cry present, birth weight – 2.5 kg. The child was increasingly active since birth, don’t use to listen or obey. In class don’t use to do work, tears paper, writing on it, gets 10‐15 out of 20.the client’s behavior is full of anger, shouting, when mother sleeping she do mischief, takes creams violini and lips. The client don’t play with other children, use of hits other children, say to others that her mother hits her. Dresses like teacher. Plucking of hairs (Alopecia due to
  • 35.
    Page | 35 trichotillomania).The complaints increase in summer weather. Sleep good (10 pm‐ 9am) eats papers since 1‐2 Days. • Date of onset of illness‐ since childhood. • Treatment taken‐ No treatment taken so far • Got well any time in between, duration of such period‐ N/A • Has to take leave from work place/ school/ college‐ N/A • Cannot carry on routine work‐ Yes • Has to depend on others for everything‐ No • Want to lie down and take rest‐ Yes Interview with family members • Relationship‐ Mother • Educational history of client‐ KG class • School / college‐ GRM Public Senior secondary School • How is academic performance ‐ Average, 10‐15 out of 20 • Does client matches parents and teachers expectations‐ Yes • How has the performance been over years? In KG Class • Any sudden deterioration in performance‐ No • Any complaints received‐ Hits other children in class, doesn’t Sits/stay at one place. • Has they done anything so far to correct it? What? No • When did they decide to consult a mental health specialist? When someone told her to come here and take treatment from here. Past History‐ Nothing Significant Family History‐ No history of any mental/ Physical disorder in family. All apparently healthy and alive Mental status examination Presentation‐ The client is well oriented, friendly, and well‐groomed, under shirt visible and is over the dress. A hairless patch noted on the scalp. Dressed as per the season. Hygiene maintained. Social interaction with staff and others in waiting room‐ Greeting the staff. Greeting all the interns she knew as ‘ Hi didi’ ‘Hi didi’
  • 36.
    Page | 36 Ifsomeone accompanying and who‐ Mother Talking to himself in waiting room‐ No Pacing up/down the office floor‐ Yes, running all over the place, not sitting for long at one place. Rapport building‐ Rapport was build by greeting the client and asking her some basic questions about herself. Appearance – if interested in self and grooming/ able to take care of self‐ Yes Movement and behavior 13. Gait‐ Nothing abnormal Detected 14. Posture‐ Nothing abnormal Detected 15. Coordination‐ Nothing abnormal Detected 16. Eye contact‐ Present 17. Facial expressions‐ as if getting bored. 18. Walking / coordination problem if any‐ No Affect‐ Elated mood Mood‐ Happy Speech‐ Can’t pronounce words from `La’ and `ra’, Language articulation Problem Volume‐ High Rate/speed‐ Normal Length of answers‐ Short Appropriateness of answers‐ Yes Clarity of answers‐ Unclear Thought content‐ Clear, Normal, Listening, Obeying, understands the situation, no Intrusive thoughts Hallucinations‐ No Delusions‐ No Dissociation‐ No Obsessions‐ No Thought process‐ Clear • Irrelevant details‐ No • Repeated words phrases‐ No • Interrupted thinking‐ No • illogical connections‐ No
  • 37.
    Page | 37 Cognition •Orientation – Well oriented to time, people and place • Long term memory‐ Intact • Short term memory‐ Intact • Ability to perform a simple arithmetic task‐ Yes • General intellectual level‐ Average • Ability to think abstractly‐ Yes • Ability to name specified substances/ read / write complete sentences‐ Yes, can name sentences, can’t write full sentences, can write basic alphabets and numbers. Macrographia, writing big. • Ability to understand and perform a task‐ Yes • Ability to draw a simple map or copy a geometrical figure‐ Yes • Inability to tell right left‐ Yes Judgment and Insight– Present as per age Work history‐ Not applicable Marital history‐ Not applicable • Answers to be in verbal language? How was client answering? Yes • Hesitant? No • Free communication? Yes • Evading any answer? No • Focusing on interview‐ Yes, but easily distracted • Diverted easily distracted‐ yes • Have the questions to be repeated no of times‐ No • General demeanor of client‐ • Was client in hurry/ unwilling to continue interview‐ No • Pause in certain questions‐ No • Cooperative ready to answer‐ Yes • Showing concern about his illness? No
  • 38.
    Page | 38 Summary Clientis a 7 year old female child with hyperactive behaviour and tendency to pluck the hair which has lead to a Hairless patch on the scalp. Provisional Diagnosis Attention deficit Hyperactivity disorder with trichotillomania Differential diagnosis • Oppositional defiant disorder: Absence of any negativity, hostility, and defiance. No resistance to tasks given is observed • Specific Learning Disorder: No serious concern noted in learning and using acaedemic skills. • Reactive attachment disorder: Absence of inhibited, emotionally withdrawn behavior toward adult caregivers. High social and emotional responsiveness to others.Good history of caregiving. Suggested interventions • Pharmacotherapy‐ To Decrease Hyperactivity • Family therapy‐ To increase family support • Behavior modification therapy‐ To increase wanted behavior and decrease unwanted behavior.
  • 39.
    Page | 39 CASE‐IV Client’s Name‐ Date‐ Registration no‐ Age‐ 12 Years Gender‐ Male Child Address‐ Educational qualifications‐ 3rd Standard Occupation‐ Student ‐ Marital status‐ Unmarried Clients stay with parents‐ Yes Stay with Spouses‐ No Siblings, how many‐ One Younger brother Position in family‐ Elder Child Anyone in family suffered from mental disorder‐ No Anyone in family suffered from physical disorder‐ grandfather paralyzed at 60 years, Clients maternal uncle had history of seizures. Informant Relation‐ Father Source of Referral‐ Relatives Presenting complaint (in words and as in sequence told by the Father) • Dimaag mein kami hai • Jhooth bolta hai • Khana nai khata, Kamzor hai History of Present Illness‐ The client was born as a full term normal vaginal delivery at home, Birth cry positive, Birth weight‐ 750 g (Pauna kilo). The mother had weakness in extremities, Body ache, Heaviness from beginning of 2nd trimester. There were financial strains and tensions during pregnancy as no one was working then. The child was admitted 12 hours after birth due to fits, for which he was treated for 22 days in the ICU. Then he was brought home, where he developed diarrhea, vomiting. For which again allopathic treatment was started and it got well. The client had his milestones on
  • 40.
    Page | 40 time.The client is now 20 Kg. Schooling since 3‐4 years, the child is very notorious in school doesn’t do work at school. • Date of onset of illness‐ Subnormal intelligence noted since he started going school • Treatment taken‐ No Treatment taken • Has to take leave from work place/ school/ college‐ No • Cannot carry on routine work‐ Can do routine work. • Has to depend on others for everything‐ No • Want to lie down and take rest‐ No Interview with family members • Relationship‐ Father • Educational history of client‐ attended school till 3rd class • School / college‐ Going to school, but poor performance • How is academic performance ‐ Poor • Does client matches parents and teachers expectations‐ No • How has the performance been over years? Not improved • Any sudden deterioration in performance‐ No, Bad from starting • Any complaints received‐ Yes, don’t study, roams in the class • Has they done anything so far to correct it? What? No • Any improvement with their efforts? No • When did they decide to consult a mental health specialist? • Their view point‐ As per the father the child is very weak in studies, can’t study as a normal child, and is very dull. • In what ways illness caused inconvenience to them‐ No such inconvenience as such but they are just concerned about the child’ intellect and his future, what will he do, if he will be dull. Past History‐ Client born as underweight child. Family History‐ All apparently well Mental status examination Presentation‐ Poor Hygiene, dressed well as per the season but looking dirty, Infective itching rash over face and neck. Personal appearance‐ dirty Social interaction with staff and others in waiting room‐ present
  • 41.
    Page | 41 Ifsomeone accompanying and who‐ father Personal grooming‐ hair nicely groomed Talking to himself in waiting room‐ No Pacing up/down the office floor‐ No Rapport building‐ rapport was build by making the client sit comfortably and asking the client his name and what does he do. Appearance – if interested in self and grooming/ able to take care of self‐ Less interested Movement and behavior 19. Gait‐ Nothing Abnormal detected 20. Posture‐ Nothing Abnormal detected 21. Coordination‐ Intact 22. Eye contact‐ Intact 23. Facial expressions‐ Nothing Abnormal detected 24. Walking / coordination problem if any‐ No Affect and Mood‐ Normal neither too happy nor sad Speech‐ No speaking difficulty, normal speech but repeating end of questions. Volume‐ Low Rate/speed‐ Normal Length of answers‐ short but appropriate length Appropriateness of answers‐ Yes Clarity of answers‐ Yes Thought content‐ Normal, No Intrusive thoughts Hallucinations‐ No Delusions‐ No Dissociation‐ No Obsessions‐ No Thought process‐ Slow • Irrelevant details ‐ Absent • Repeated words phrases‐ Thinks and repeats questions, repeating end of questions like when asked to tell a story he said kahani sunaun, kahani sunaun, when as what does he like to eat ~ he said `mujhe lagta hai, lagta hai’ • Interrupted thinking‐ No, Absent • Illogical connections‐ No
  • 42.
    Page | 42 Cognition •Orientation – Client well oriented to people, place and time • Long term memory‐ Intact • Short term memory‐ Intact • Ability to perform a simple arithmetic task‐ No • General intellectual level‐ Below Normal • Ability to think abstractly‐ No • Ability to name specified substances/ read / write complete sentences‐ Decrease intellect can write words or sentences • Ability to understand and perform a task‐ yes, verbal tasks • Ability to draw a simple map or copy a geometrical figure‐ yes can draw a circle • Inability to tell right left‐ Yes Judgment –Intact Insight –Intact Work history‐ None Marital history‐ Unmarried • Answers to be in verbal language? How was client answering? Yes • Hesitant? ‐ No • Free communication? Yes • Evading any answer? No • Focusing on interview‐ Yes • Diverted easily distracted‐ No • Have the questions to be repeated no of times‐ No • General demeanor of client‐ slow • Was client in hurry/ unwilling to continue interview‐ No • Pause in certain questions‐ Yes in all questions requiring thinking • Cooperative ready to answer‐ Yes Summary The client is a 12 year male child with decrease scholastic performance as per his age.
  • 43.
    Page | 43 ProvisionalDiagnosis Mild Mental Retardation Differential diagnosis Autism: Presence of Eye Contact, Good Social Skills, Absence of No Repitative Behaviour. Suggested interventions • Behaviour Therapy‐ To encourage the child to learn and increase his self confidence • Family Therapy‐ To increase family support to the child, telling the parents not to punish the child but in turn encouraging him to do work and complimenting him on his works to increase self confidence
  • 44.
    Page | 44 CASE‐V Client’s Name‐ Date‐ Registration no‐ Age‐ 21 years Gender‐ Female Address‐ Educational qualifications‐ studied till 5th standard Occupation‐ None Source of Income‐ Brother – Tikki Wala Shop Marital status‐ Divorced Clients stay with parents‐ Yes with Mother and Elder brother Stay with Spouses‐ No Siblings, how many‐ 2 Sisters and 1 elder brother Position in family‐ Youngest‐ 4th Child Anyone in family suffered from mental disorder‐ No Anyone in family suffered from physical disorder‐ Clients father chronic alcoholic died from paralytic attack Informant Relation‐ Mother and Brother Source of Referral‐ Relatives Presenting complaint (in words and as in sequence told by the client) • Paglon ki tarah rehti hai, Khud se bolti hai • Iske peeche jin padha hai History of Present Illness‐ The client was married on 8th July 2010, but she returned a week after to her parent’s family as her husband was a criminal and was put in jail. She had her divorce in 26th July 2011. Her 3rd Sibling (sister) was married in 5th december2005, and got a child after 4 years of marriage. She is very close to her jija and obeys his every wish. Also the jija (who has a shop of Bidi, cigarette) gets angry and use to
  • 45.
    Page | 45 beathis didi also because of which her didi also now obeys whatever he says. The client was forcefully brought to the hospital for admittion, she created a fuss in the waiting section where she got on the floor and was crying very loudly in a knee elbow position. On taking the case from the mother her mother said that ‘ye apne jija ki baat itni maanti hai ki agar abhi wo phone karke bula le to bhaag ke unke pass chali jaegi’. On enquiry more about the history from the mother she told that the client was staying with her 3rd sibling (sister) after the birth of their child. There only after some time, she had injured her leg for which her sister and jija took her for treatment. As per the sister told the mother ‘ilaaz karva ke a rhe the to railway ki patri pe gir gyi thi jahan se jin iske peeche lag gya’. Since then the client started behaving abnormally, use to develop trance like states? In which she use to scream a lot, after the state it was found that her clothes use to be torn, also near her neck and chest, and she had scratch marks over her body, face, chest, after every episode. She use to scream and tell in altered voice reflecting that there is a male possessing her body and he says he is possessing her as she looks like just his wife and he needs her body and would not leave her. She got bed ridden and use to cry all time. The client’s mother on seeing the day by day deteriorating condition of the mother brought her to her own home. On some relatives consultation she was taking the client to a dargah, on way the client was speaking in altered voice and asking them not to take her to the mosque there she was made to drink some holy water and some oil was put in her ear. On returning from there client could not use her legs and walk at all, the client said in an abnormal voice that because she was taken to the mosque now the Jin had done this. Later she was taken to a pooja where before going only the client stopped talking and it was said that the jin is doing this, afraid from this the family members brought her back to home. Since then the client is at home only and getting the episodes of possessions, she is not talking else when she has an act of possession. During the time of admission in IPD she was very reluctant and doing tantrums and saying again and again to take her back. She was saying no one could treat her. No doctor could treat her. • Date of onset of illness‐ 6 months back
  • 46.
    Page | 46 •Treatment taken‐ No medical treatment taken • Got well any time in between, duration of such period‐ No • Was there any precipitating factor at each relapse? The illness is continuing since 6 months, not got well in between but the symptoms worsen whenever any type of treatment is thought to start. • Any other treatment tried in between‐ the client had been taken to a dargah but after that client stopped using her lower limbs and after she was taken to a pooja she stopped talking, now only talks when the possession attacks comes. • Effect of treatment‐ conditioned worsened because of no proper medical treatment given. • Impact of illness on daily life‐ she is not leading a normal life, is bedridden and just lies on bed. • Cannot carry on routine work‐ the client not doing any work, just lying on the bed, the mother only looks after her, the client indicates whenever there is any urge to urine or stool and mother takes her. Has to depend on others for her care, want to lie down and take rest. Interview with family members • Relationship ‐ Mother • Educational history of client‐ studied till 5th standard • Family members (Mother, brother and sister) are very much stressed and worried about the client and want her to get ready. The financial condition of the family is also not good. • Their view point – On asking the mother she said that she suspects the 3rd sibling sister and her husband had done this to hide their some wrong work, they had done something wrong with the client and to hide that they had done made her eat something or done something. Mother strongly suspects some connection of the jija with the client’s illness as jija is not a good person. She wants to keep the daughter away from them as the sister and jija may come and tell the client not to take the treatment and the client will stop the treatment immediately.
  • 47.
    Page | 47 •In what ways illness caused inconvenience to them‐ the brother’s and mother’s work had been affected a lot because of the client’s illness. There is financial strain due to it as they had to give their time to look after the client. Past History‐ Injury of leg – fall from stairs when in sister’s house – 6 months back Fall on railway line‐ Injury on Head and back – 6 months back Family History Father was chronic alcoholic, got a paralytic attack in 2006, and was taken to DDU and RML for treatment, died in December 2012. All others apparently well and no other family history of mental/Physical illness can be elicited. Mental status examination Presentation‐ Dressed in clothes as per the season hair, dry, rough and uncombed, the client tored her dress after the attack in the OPD after which she was admitted. Appearance – Not interested in self and grooming Social interaction with staff and others in waiting room‐ Absent If someone accompanying and who‐ Mother, Brother and 2nd sibling (sister) Talking to himself in waiting room‐ client made a chaos in the waiting room where she got on the floor and was crying very loudly in a knee elbow position. She wasn’t moving there at all, was very stiff and wanted to go home. Pacing up/down the office floor‐ No Rapport building‐ Could not be achieved as the client didn’t want to be treated and admitted. Movement and behavior 25. Gait‐ Not Walking 26. Posture‐ Stiff lying in knee‐elbow position 27. Coordination‐ Present 28. Eye contact‐ Present 29. Facial expressions‐ Of Anger alternating with crying 30. Walking / coordination problem if any‐ Not Walking
  • 48.
    Page | 48 Affect‐Over reaction Mood ‐Client’s answer‐ anger alternating with crying spells Speech‐ No difficulty in speech could be elicited when the client is crying as she speaks then. Volume‐ High Rate/speed‐ Normal Length of answers‐ Neither too long nor too short Appropriateness of answers‐ Yes sometimes she answers as when we respond to what she is screaming. Else she don’t answers and is busy screaming ‘ le chalo’ ‘Le chalo yahan se’ Clarity of answers‐ yes Thought content‐ ok Hallucinations‐ Client not answering to questions Delusions‐ Client not answering to questions, No as per the mother. Dissociation‐ Client not answering to questions Obsessions‐ Client not answering to questions Thought process‐ Client not answering to questions • Irrelevant details‐ No • Repeated words phrases‐ repeating ‘le chalo’ ‘yahan se le chalo’ • Interrupted thinking‐ No • illogical connections‐ No Cognition • orientation – client is well oriented to Time/People/Place • long term memory‐ Could not be elicited • short term memory‐ Could not be elicited • ability to perform a simple arithmetic task‐ Could not be elicited • general intellectual level‐ Could not be elicited, looks average intelligence, as sometime after when we left the client she came out of her room on floor and when it was tried to take her back, she knew how to get her feet entangled in the furniture so as to resist, once the leg was freed in the next bed she again tangled her leg. • ability to name specified substances/ read / write complete sentences‐ Could not be elicited • ability to understand and perform a task‐ No • ability to draw a simple map or copy a geometrical figure‐ Could not be elicited
  • 49.
    Page | 49 •inability to tell right left‐ Could not be elicited Judgment – Could not be elicited Insight – do you think you are ill? She says that her illness can’t be treated by any doctor Work history‐ N/A as client not working Marital history‐ Divorced from husband 4 years back and husband did not tried to contact after that, the husband was in jail, she left the husband 1 week after the marriage • Answers to be in verbal language? How was client answering? Yes sometimes • Hesitant? No • Free communication? Yes • Focusing on interview‐ No • Diverted easily distracted‐ Yes • Have the questions to be repeated no of times‐ Yes • General demeanor of client‐ lying on bed crying • Was client in hurry/ unwilling to continue interview‐ yes very much unwilling to take treatment also • Pause in certain questions; No • Cooperative ready to answer‐ No • Showing concern about his illness?‐ No Summary The client is a 21 year female, suffering from loss of sense of reality, she has been presenting with attacks as if a male spirit has possessed her body during which she screams, gets marks on her body (Face, chest), clothes gets tored. She is behaving madly and don’t want to get treated. Provisional Diagnosis Dissociative disorder Differential Diagnosis
  • 50.
    Page | 50 •Schizophrenia – Absence of any do not have delusional explanations for the phenomena in a personified way Suggested interventions • Pharmacotherapy – To decrease clients restlessness and dissociative symptoms • Family counseling ‐ To tell them that the client’s condition is a medical disorder and needs a proper medical treatment with compliance and they should have patience and should cooperate in the treatment • Behaviour modification therapy‐ To increase positive wanted behavior and decrease unwanted behavior
  • 51.
    Page | 51 CASE‐VI Client’s Name‐ Date‐ Registration no‐ Age‐ 21 Years Gender‐ Male Address‐ Educational qualifications‐ Not Gone to School Marital status‐ Unmarried Clients stay with parents‐ Yes Stay with Spouses‐ N/A Siblings, how many‐ One elder brother Position in family‐ Younger brother Anyone in family suffered from mental disorder‐ No Anyone in family suffered from physical disorder‐ No Informant Relation‐ Mother Source of Referral‐ Family Presenting complaint (in words and as in sequence told by the Mother) • Dara hua hai • Teen din se soya nai • Idhar udhar dekhta rehta hai, ek dum dar jata hai History of Present Illness‐ • Onset‐ 3 days back • Treatment taken‐ In the past for seizures from Lady Hardinge Medical college • Got well any time in between, duration of such period‐ Yes with medication • Was there any precipitating factor at each relapse? The client is a known case of cerebral palsy with seizure disorder, he had gone to a wedding and was returning in the night train, it was a 24 hour journey and the door of the train was making sound all night due to which he could not sleep and was whole night
  • 52.
    Page | 52 wakingand seeing at the door. Since then after coming home he is crying, not sleeping and is afraid. • Any other treatment tried in between is taking treatment since childhood for seizures. Had undergone multiple tendon (Hamstring and Obturator) release operations for the stiffness, involuntary urination. • Effect of treatment‐ Seizures have decreased now and the client now understand things and interact with others • Impact of illness on daily life‐ Is not able to go to school or do any work on his own. Cannot carry the routine works, has to be assisted to toilet as cant stand and walk properly. Has to depend on others. Interview with family members • Relationship‐ Mother • Educational history of client‐ not gone to school • School / college‐ N/A • As per the family members the child got afraid while returning in the train. • In what ways illness caused inconvenience to them‐ the client is leading a dependent life, he needs an assistance to do things. Past History History of similar episode in 2009 Family History All Family members are apparently healthy, No History of Physical, mental or any similar illness can be elicited. Mental status examination Presentation‐ Client is of an obese built, well dressed as per the season in a wheelchair and was having increased salivation If someone accompanying and who‐ Mother and Brother Social interaction with staff and others in waiting room‐ Decreased Talking to himself in waiting room‐ No
  • 53.
    Page | 53 Pacingup/down the office floor‐ No Rapport building‐ Rapport was tried to build by asking the basic details from the client and taking his name. If interested in self and grooming/ able to take care of self‐ Yes a little Movement and behavior 31. Gait‐ can walk only with support 32. Posture‐ sitting bending sideways in the wheelchair 33. Coordination‐ Not present 34. Eye contact‐ Not present 35. Facial expressions‐ Anxious with wrinkles on forehead and mouth drawn open 36. Walking / coordination problem if any‐ Can walk only with support Affect‐ Client was looking anxious and afraid, over reaction to stimulus Mood‐ Sad Speech‐ Slurred speech, Volume‐ high, Rate/speed‐ slow Length of answers‐ Short Appropriateness of answers‐ Yes Clarity of answers‐ Yes Thought content‐ Decreased Hallucinations‐ No Delusions‐ No Dissociation‐ No Obsessions‐ No Thought process‐ Diminished Cognition • Orientation – Oriented to people and place • Long term memory‐ Intact • Short term memory‐ Intact • Ability to perform a simple arithmetic task‐ Can’t be done • General intellectual level‐ Subnormal • Ability to think abstractly‐ No • Ability to name specified substances/ read / write complete sentences‐ No, can’t write • Ability to understand and perform a task‐ only tasks which can be done sitting and not involving high intellect
  • 54.
    Page | 54 •Ability to draw a simple map or copy a geometrical figure‐ No, grasping not there, can’t hold pen, pencil • Inability to tell right left‐ No Judgment – Not present Insight – Not Present • Answers to be in verbal language? How was client answering? Yes • Hesitant? No • Free communication? No as client can’t speak properly • Evading any answer? No • Focusing on interview ‐ No , client was anxious and looking here and there • Diverted easily distracted‐ Yes • Have the questions to be repeated no of times‐ Yes • General demeanor of client‐ Sitting in wheelchair, anxious, bending on left side, Mouth open • Was client in hurry/ unwilling to continue interview‐ No • Pause in certain questions‐ No • Cooperative ready to answer‐ Yes • Showing concern about his illness? No Work History‐ None Marital History‐ Not Applicable as unmarried Summary The client is a 21 year old male child presenting with fear and anxiety since returning from a 24 hour train journey in a train. As per the informant the journey was in the night and the door of the train cabin was loose and making a lot of noise the whole night due to which the patien could not sleep and since then he is very afraid, not speaking and interacting as before.
  • 55.
    Page | 55 ProvisionalDiagnosis Cerebral Palsy with Phobia Differential diagnosis Autism – Autism is not present as the client has good social skills and responsive behavious, no history of repitative bahviour could be elicited. Suggested interventions • Pharmacotherapy – To decrease anxiety • Family therapy ‐ To increase family support and Interaction • Speech therapy – To make speech more clear • Occupational Therapy‐ For managing cerebral palsy so that client can engage in some work and do something creative.
  • 57.
    Page | 57 •Got well any time in between, duration of such period‐ No • Was there any precipitating factor at each relapse? Nothing could be elicited by clients history • Effect of treatment‐ with the previous treatment she had increased somnolence. • Impact of illness on daily life‐ she is not able to take care of herself, keep hygiene properly because of which the mother also cut her hairs short as she could not take care of it. The client is not going to school since 1st standard • Has to take leave from work place/ school/ college‐ Yes she could not attend the school • Cannot carry on routine work‐ Yes • Has to depend on others for everything‐ No • Want to lie down and take rest‐ Yes • Don’t want to do anything‐ Yes Interview with family members‐ • Relationship‐ Mother • Educational history of client‐ studied till 1st standard • How is academic performance ‐ Was not good in studies • Does client matches parents and teachers expectations‐ No • Their view point‐ she is mad. On talking with the mother it was noted that she had many bruises and injury on her body, when asked she told it’s all because of the client. The client come s suddenly from behind when the mother is resting or doing some work and tightly holds her, bites her and then go away after biting. Client is disruptive, Moody, doesn’t obey anything, does whatever she want to do, goes out to roam, wander on streets, bring things from street vendors without paying for it • In what ways illness caused inconvenience to them‐ the child is causing distress to the mother as she has to take care of her whole time and also the client bites her because of which there were many injuries over the body.
  • 58.
    Page | 58 FamilyHistory: The client’s cousin had similar symptoms Mental status examination Presentation‐ Dressed like a boy in trouser and shirt and boy cut hairs Personal appearance‐ Neat, Well dressed as per the season, thin and tall female If interested in self and grooming/ able to take care of self‐ Yes Social interaction with staff and others in waiting room‐ No interaction with others. If someone accompanying and who‐ Mother Talking to himself in waiting room‐ Yes, screaming “ Bhagwann” “ Bhagwaan” while waiting and then laughing inappropriately. Singing songs changing it and inducing words like pagal in the song Pacing up/down the office floor‐ Sits for sometime, then goes out of the room then comes back Rapport building‐ Could not be achieved, Client not cooperative Movement and behavior 37. Gait‐ Nothing abnormal detected 38. Posture‐ Nothing abnormal detected 39. Coordination‐ Nothing abnormal detected 40. Eye contact‐ Present 41. Facial expressions‐ Notorious, smiling, as if will do something mischievous 42. Walking / coordination problem if any‐ No Affect‐ Over reaction, shouting words. Mood ‐clients answer‐ Elevated Speech‐ loud speech, High Volume, normal Rate, Length of answers‐ Unco‐operative client Appropriateness of answers‐ Unco‐operative client Clarity of answers‐ Unco‐operative client Thought content‐ Unco‐operative client, singing songs including god and abusive language Hallucinations‐ Unco‐operative client Delusions‐ Absent Dissociation‐ Absent Obsessions‐ Nothing as such
  • 59.
    Page | 59 Thoughtprocess • Irrelevant details – answers inappropriately, singing inappropriately, Shouting “pagal” word again and again and singing bhagwaan bhagwaan and including the word pagal in the songs also. laughing inappropriately • Repeated words phrases‐ repeating work pagal and Bhagwann with herself Cognition • Orientation‐ Oriented to place, people and time. • Long term memory‐ Cant be elicited as client not answering • Short term memory‐ Cant be elicited as client not answering • Ability to perform a simple arithmetic task‐ Cant be elicited as client not answering and following commands • General intellectual level‐ Cant be elicited as client not answering and following commands • Ability to name specified substances/ read / write complete sentences‐ Cant be elicited as client not answering and following commands • Ability to understand and perform a task‐ ‐ Cant be elicited as client not answering and following commands • Ability to draw a simple map or copy a geometrical figure‐ Cant be elicited as client not answering and following commands • Inability to tell right left‐ Can’t be elicited as client not answering and following commands, but mother says no. Judgment‐ Can’t be elicited as client not answering Insight‐ Client not answering questions but herself laughing and repeating words Marital history‐ Not applicable as Unmarried Work History‐ None Summary The client is a 13 years girl, having psychotic symptoms like hallucinations, screaming, biting, singing abusive songs.
  • 60.
    Page | 60 ProvisionalDiagnosis Psychotic Disorder Differential diagnosis Attention deficit hyperactivity disorder: Presence of Hallucinations, Child out of touch with reality. Eccentricities of behavior, Lack of social friends Suggested interventions • Pharmacotherapy‐ To reduce violent tendencies and aggressiveness. • Behaviour therapy – To increase positive behavior and decrease unwanted behavior. • Family therapy – To increase family support and help family to cope up with the problems faced due to the child’s illness
  • 62.
    Page | 62 •Date of onset of illness ‐ since birth • Treatment taken‐ taking allopathic treatment since 9 months of age. • Got well any time in between, duration of such period ‐ No, is relieved by taking treatment but not total well. • Was there any precipitating factor at each relapse? The condition is continuous. The mother was very stressed mentally as well as physically due to father being a alcoholic and as she had severe cough which wasn’t getting controlled, before Raghav in previous pregnancies the client had hypertension and also had 2 spontaneous abortion at 2 and 3 months of gestation in 1st and 2nd gestation. • Any other treatment tried in between‐ Ayurvedic treatment taken for a week but after a week he developed diarrhea so treatment withdrawn. • Effect of treatment‐ Seizures stopped with allopathic medicines, is now less violent and less tendency to head banging and self biting • Impact of illness on daily life‐ The client is not able to take care of self, can’t eat food and go to toilet on his own. Has to depend on others for everything. • Has to take leave from work place/ school/ college‐ Not gone school anytime Interview with family members • Relationship ‐ Mother and Father • As the client was unable to talk information was elicited from the parents (especially mother) • In what ways illness caused inconvenience to them‐ Mother is concerned as the child is not well and they have to look after the child as he is not able to do anything and the mother has to be with him and take care of him all time. • Educational history of client – Client not gone to school • School / College ‐ Not Applicable • How is academic performance ‐ Not Applicable • Does client matches parents and teachers expectations ‐ Not Applicable • How has the performance been over years? – Not Applicable
  • 63.
    Page | 63 •Any sudden deterioration in performance – Inability to perform simple tasks like eating, going to toilet. • Any complaints received‐ Not Applicable • Has they done anything so far to correct it? What? – Taking allopathic treatment since 9 months of age. • Any improvement with their efforts? – Decrease in anger and irritability, biting. • When did they decide to consult a mental health specialist? – Since 9 months of age when complaint wasn’t getting relieved on its own. Mental status examination Presentation‐ The client was well dressed, drowsy lean child, with Hyper‐ pigmented scar marks over dorsum of both hands and arms. Was dressed neatly, maintaining the hygiene, dressed according to season appropriate. Due to increased salivation, the saliva was dribbling through mouth which had to be cleaned by the attendant. Semi conscious state, due to the effect of allopathic medication. Personal grooming‐ Well groomed Hygiene‐ Well maintained If client dressed according to season appropriate‐ Yes If interested in self and grooming/ able to take care of self ‐ No Social interaction with staff and others in waiting room‐ Bad, no interaction could be there. If someone accompanying and who‐ Accompanied by mother and father Talking to himself in waiting room‐ No Pacing up/down the office floor‐ No Rapport building‐ Rapport can’t be established Movement and behavior 43. Gait – Can’t walk without support 44. Posture – Reclining on one side of chair as client is semi conscious 45. Coordination‐ Nothing abnormal detected 46. Eye contact‐ Absent as semi conscious 47. Facial expressions ‐ Nothing abnormal detected 48. Walking / coordination problem if any‐ Can stand and walk with support. Affect‐ Lack of response
  • 64.
    Page | 64 Mood‐Sleepy, somnolent. Speech – Absent, not attained. Volume ‐ Not Applicable Rate/speed ‐ Not Applicable Length of answers ‐ Not Applicable Appropriateness of answers ‐ Not Applicable Clarity of answers ‐ Not Applicable Thought content ‐ Not Applicable Hallucinations ‐ No Delusions ‐ No Dissociation ‐ No Obsessions ‐ No Cognition • Orientation – Can’t be elicited • Long term memory – Can’t be elicited • Short term memory – Can’t be elicited • Ability to perform a simple arithmetic task – Can’t be elicited • General intellectual level ‐ Subnormal • Ability to think abstractly ‐ Absent • Ability to name specified substances/ read / write complete sentences ‐ Absent • Ability to understand and perform a task ‐ Absent • Ability to draw a simple map or copy a geometrical figure ‐ Absent • Inability to tell right left‐ Absent Judgment – Absent Insight – Can’t be elicited Summary The client is a 9 year Male child staying with parents and having seizure disorder and mental retardation with tendency to self biting. Provisional diagnosis Pervasive Development Disorder with Mental retardation with self biting tendency.
  • 65.
    Page | 65 Differentialdiagnosis Cerebral palsy‐ Normal EEG. No symptoms of Motor Disorder. Suggested interventions • Pharmacotherapy‐ To control seizures, anger and self biting tendency • Family therapy‐ Family therapy is generally initiated because of the symptomatic of dysfunction within the family system as a whole. The therapist focuses on the interaction between family members, analyzing the role played by each member in maintaining the system. Family therapy can be especially helpful in this case to make the environment at home more congenial, and treatment of father for alcoholism.
  • 66.
    Page | 66 CASE‐IX Client’s Name‐ Date Age/ Sex‐ 42 years / Male Address‐ Educational qualifications‐ BA Graduate Occupation‐ Presently not employed (Private Job 2 years before) Income‐ Not working at present Marital status‐ Married Clients stay with parents‐ Yes Stay with Spouses‐ Yes Siblings, how many‐ Three sisters Position in family‐ Eldest Child Anyone in family suffered from mental disorder‐ No Anyone in family suffered from physical disorder‐ Mother had a history of convulsions because of raised Blood sugar, son is having autism with seizure disorder, Daughter is having Haemangioma over forhead. Informant Relation‐ Wife Source of Referral – Brought by wife Presenting complaint (As per Informant) • Sharaab Peete hain • Bethe bethe baat karte rehenge • Chehre parr haath karte rahenge • Gusse mein bolte hain khud se, khud bol rhe the ‘bolte a rha tha’ • Guusa karte hain, Sunte nai h Presenting complaint (As per Client) Accident ho gya the tab se per mein pain hai, dard hota hai, zyada kaam nai kar sakte.
  • 67.
    Page | 67 Historyof Present Illness‐ Client is a chronic alcoholic since more than 10 years, because of which there were many tensions at home from the beginning of marriage. Conditions worsened 2 years back when the client (intoxicated) was trying to get on a DTC bus and the driver closed the door of buss because of which the person fell and his right foot got severely crushed under the buss. The client had a plastic surgery immediately for this. But since then he is complaining of pain in the affected feet. He has not joined back his job and is now resting at home and says he can’t walk and there is pain in leg after walking for 10‐15 minutes. He still hasn’t quitted alcohol and drinks it whenever he gets money. He has also done a case against the government for negligence. Both the client and his wife aren’t working and their child is having disability (Seizures and mental retardation), there are financial constraints at home. The client’s father is the sole working member of the family. Client is reserved doesn’t share his thoughts with others. Get angered at slight things like when something is not kept at its proper place or when he is interrupted while doing some work. Gets involved in quarrels and is always saying things in anger. Saying things when walking in anger on roads. Sleep is sound sleeping in afternoon for 2‐2 ½ hour and in night from 12 to 8o’clock in morning • Date of onset of illness‐ Alcoholic since 12 years. • Treatment taken‐ No treatment taken • Was there any precipitating factor at each relapse? Increased alcoholism after the accident. • Impact of illness on daily life‐ Had left the job after the accident • Doesn’t want to do a job is looking for the case to get finished which he has done for negligence. • Cannot carry on routine work‐ No, can do routine work, but can’t walk continuously for more than 10 minutes. • Has to take leave from work place/ school/ college‐ Yes • Has to depend on others for everything‐ No
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    Page | 68 Interviewwith wife • Their view point‐ The wife is very much concerned about the husband’s alcoholism and anger. She wants him to leave alcohol. • In what ways illness caused inconvenience to them‐ The fathers alcoholism has lead to financial constraints at home, whatever money he gets anytime he goes to buy alcohol and the wife is very concerned with this as their child is very small (9 years) and have seizure and is mentally retarded. Educational history of client‐ BA Graduate Mental status examination Presentation‐ Middle Aged client, Mesomorphic Built, Well groomed and dressed as per the season, Hygiene maintained, Well dressed, with a saffron tilak on forehead. If interested in self and grooming/ able to take care of self‐ Yes Social interaction with staff and others in waiting room‐ Nothing abnormal detected If someone accompanying and who‐ Wife Talking to himself in waiting room‐ No Pacing up/down the office floor‐ No Rapport building‐ Rapport was build by making the client sit comfortably and engaging him in general conversation about his complaints. Movement and behavior 1. Gait‐ Nothing abnormal detected, walking normally, no sign of limping or pain could be objectively seen. 2. Posture‐ Nothing abnormal detected 3. Coordination‐ Nothing abnormal detected 4. Eye contact‐ Lost in between 5. Facial expressions‐ Client having facial tics as blinking of the left eye and restricted movements on right side of the face. 6. Walking / coordination problem if any‐ Nothing abnormal detected Affect‐ normal, happy, nothing abnormal detected Mood ‐ Normal
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    Page | 69 Speech‐Normal, No difficulty in speech noted Volume‐ Moderate, Nothing abnormal detected Rate/speed‐ Nothing abnormal detected Length of answers‐ Appropriate Appropriateness of answers‐ Yes Clarity of answers‐ Clear Thought content‐ Clear Hallucinations‐ No Delusions‐ No Dissociation‐ No Obsessions‐ No Thought process‐ Normal thoughts of day to day events, no intrusive thoughts Cognition • Orientation ‐ Well oriented to time, people and place • Long term memory‐ Intact • Short term memory‐ Intact • Ability to perform a simple arithmetic task‐ Yes • General intellectual level‐ Average • Ability to name specified substances/ read / writes complete sentences‐ Yes • Ability to understand and perform a task‐ Yes • Ability to draw a simple map or copy a geometrical figure‐ Yes • Inability to tell right left‐ Yes Judgment – Intact Insight – Yes, Present on questioning specifically Work history • Occupation‐ Left job 2 years back after foot accident • Regular on work? No • Any complains of workplace? What? ‐ No complaints • Any leaves? How long? Not gone since 2 years • Anytime reluctant to go to office? ‐ Yes, after the accident • When was the time when client was reluctant? ‐ After the accident
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    Page | 70 •Reasons given by client for not attending work? ‐ Foot accident • Any complaint of performance? ‐ No • Client relationship with people in workplace ‐ Good • Boss‐ Ok • Colleagues‐ Ok • Subordinates‐ Ok • Anyone bothering at workplace‐ No Marital history • Day to day dealings‐ Present, does day to day work • Sex life‐ No complaints • Work relationship (spouse is working if)‐ No • Relationship with children‐ Good, close to children • Relationship with opposite sex‐ Ok • Decision making‐ Present • Sharing of work at home‐ Yes • Relationship with spouse’s relatives‐ Normal relationship • Relationship with spouse’s friends‐ Normal relationship • Answers to be in verbal language? How was client answering? Yes • Hesitant? No • Free communication? Yes • Evading any answer? He wasn’t telling about his alcoholic tendency till it was asked specifically, and wasn’t guilty about the same, said there is nothing wrong in drinking alcohol. • Focusing on interview‐ Yes • Diverted easily distracted‐ No • Have the questions to be repeated no of times‐ No • General demeanor of client‐ Cooperative • Was client in hurry/ unwilling to continue interview‐ No • Pause in certain questions‐ No • Cooperative ready to answer‐ Yes • Showing concern about his illness? Yes
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    Page | 71 Summary Theclient is a is a 42 year old male having chronic history of alcoholism and anger problems. The client had suffered an accident 2 years back of foot after which he has stopped working and is now not doing any home. The clients son is suffering from autism and seizure disorder and the clients alcoholism and not going to any job has lead to financial constraints on the whole family. Also whatever money the client gets he spends in buying alcohol with which the clients wife is very much concerned. Provisional Diagnosis Chronic Alcohol abuse Differential diagnosis • Depressive disorders: Absence of sad, empty, or irritable mood, ccompanied by somatic and cognitive changes that significantly affect the individualʹs capacity to function. • Post traumatic stress disorder: Absence of any recurrent intrusive thoughts about any traumatic event, dissociative reactions, flashblacks, avoidance to any stimuli associated with any traumatic event. Suggested interventions • Pharmacotherapy ‐ For Anger and Mood stabilization • Cognitive behavior therapy‐ To increase cognitive attitudes toward responsibility for oneʹs behavior and Decrease alcoholism • Motivational interviewing therapy—A person‐centered therapy that relies on a client’s inspiration to change and motivating the same. • Family therapy‐ To increase family support and Interaction • Deep Relaxation therapy‐ by including breathing exercises, focused muscle tensing and progressive muscle relaxation techniques to decrease anxiety and for anger management.
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    Page | 72 CASE‐X Client’s Name‐ Date‐ Age‐ 45 years Gender‐ Female Address‐ Educational qualifications‐ 8th Pass Occupation‐ Housewife Marital status‐ Married Clients stay with parents‐ No Stay with Spouses‐ Yes Family‐ three sons and 3 daughters, living with husband, Position in family‐ eldest/youngest/ middle/only child Anyone in family suffered from mental disorder‐ No Anyone in family suffered from physical disorder‐ Informant Relation‐ Daughter Source of Referral‐ Self Presenting complaint (in words and as in sequence told by the client) • Pain in neck • Dill chalta hai • Wajan badta nai hai • So ke uthungi to mann fresh nai lagta • Pet mein dard hai • Badan mein dard hai Presenting complaint (in words and as in sequence told by the Informant) • Roti rehti hain • Sir aur Badan dard batati hai • Khana theek se nai khati
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    Page | 73 Historyof Present Illness‐ • The client was apparently well 3 months back when her son stole some 20,000 rupee from home and ran away, husband was very angry with this and got into argument with the wife and beat her on the head, chest and pushed her on the floor. He had bleeding from left ear that day. Client was taken to a government hospital and investigated and sent back home. Since then she had pain in neck, unable to move it downwards, pain in left ear, find it difficult to stand from sitting position. She also complained of Mann udass rehta hai, Kuch karne ka mann nai karta, Neend nai ati, Jaldi thak jati hun, Zindagi bekar lagti hai Client’s Weight‐ 40 Kg • Onset‐ Insidious • Precipitating factor at each relapse‐ Quarrel and fight with the husband, after the husband had beaten her. • Any other treatment tried in between‐ No • Impact of illness on daily life‐ She can’t live normally, is sad. Interview with family members • Relationship‐ Daughter • Educational history of client‐ studied till 8th standard • Their view point‐ the complaints started after father has beaten her after brother left the house. • In what ways illness caused inconvenience to them‐ No inconvenience as such, she is concerned about the health of the mother. Past History‐ Nothing Significant Family History Father is a chronic alcoholic Daughter is taking psychiatric treatment
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    Page | 74 Mentalstatus examination (except in coma and unconscious clients/client with unknown language) Presentation‐ lean thin female, haphazardly dressed, hair not well groomed, looking very anxious, dressed as per the season. Hygiene ok. Social interaction with staff and others in waiting room‐ yes, Present If someone accompanying and who‐ Daughter Talking to himself in waiting room‐ No Pacing up/down the office floor‐ No Rapport building‐ Rapport was build by asking the client to sit comfortably, and asking her to relax and tell her complaints. Appearance – if interested in self and grooming/ able to take care of self‐ No Movement and behavior 49. Gait‐ Nothing abnormal detected 50. Posture‐ straight and erect, alert. 51. Coordination‐ Present 52. Eye contact‐ Present 53. Facial expressions‐ Anxious 54. Walking / coordination problem if any‐ No Affect‐ Over reaction while explaining about her pains and complaints Mood‐ Sad but highly anxious Speech‐ Fluent and sharp voice Volume‐ High Rate/speed‐ Little fast Length of answers‐ Long Appropriateness of answers‐ Yes Clarity of answers‐ Yes Thought content‐ No abnormal intrusive thoughts Hallucinations‐ No Delusions‐ No Dissociation‐ No Obsessions‐ No Thought process‐ No Irrelevant details, repeated words phrases, interrupted thinking or illogical connections Cognition • Orientation –Well Oriented to Time/People and Place
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    Page | 75 •long term memory‐ Intact • short term memory‐ Intact • ability to perform a simple arithmetic task‐ Yes • general intellectual level‐ Average • ability to name specified substances/ read / write complete sentences‐ Yes • ability to understand and perform a task‐ Yes • ability to draw a simple map or copy a geometrical figure‐ Yes • inability to tell right left‐ Yes Judgment – ask commonsense problem (as running out of a prescription medicine, or find a sealed envelope on floor)‐ Intact Insight – do you think you are ill? Intact Work history‐ None as Housewife Marital history • Day to day dealings‐ Little turmoil as Husband is alcoholic and gets angry and beats her • Sex life‐ Ok • Work relationship (spouse is working if)‐ N/A as female is Housewife • Relationship with children‐ Good • Relationship with opposite sex‐ Ok • Decision making‐ Present • Sharing of work at home‐ Yes • Relationship with spouse’s relatives‐ Ok • Relationship with spouse’s friends‐ Ok • Answers to be in verbal language? How was client answering? Yes • Hesitant? No • Free communication? Yes • Evading any answer? No • Focusing on interview‐ Yes • Diverted easily distracted‐ No • Have the questions to be repeated no of times‐ No
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    Page | 76 •General demeanor of client‐ very anxious client, when asked to be seated and some other client was in discussion she seated very carefully and erect spine and was totally quiet for a while • Was client in hurry/ unwilling to continue interview‐ No • Pause in certain questions‐ No • Cooperative ready to answer‐ Yes • Showing concern about his illness?‐ Yes, very much Summary The client is a 45 year old lady, who has got in a fight with the husband and the husband beat her. She is since then complaining of bodyache, Headache, weakness, not eating food and very anxious. Provisional Diagnosis Somatoform disorder Differential diagnosis • Anxiety Disorder – Ruled out due to presence of excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns, Undue concern about somatic symptoms • Post traumatic stress disorder: Absence of any trauma, or any recurrent intrusive thoughts about any traumatic event, dissociative reactions, flashblacks, avoidance to any stimuli associated with any traumatic event. Suggested interventions The client has been admitted in the In Clients department. • Pharmacotherapy – To Decrease anxiety and restlessness. • Other investigations‐ Referred to an orthopedic, Neurologist and surgeon for eliciting any deep injuries. • Deep Relaxation therapy‐ Including breathing exercises, focused muscle tensing and progressive muscle relaxation techniques to decrease anxiety and provide mental relaxation. A session of
  • 77.
    Page | 77 Progressivemuscle relation therapy was done with the client. By asking her to close her eyes and try to relax the mind. She was asked to take deep breaths. She was then asked to focus all her attention on the left foot and to tighten it as much as possible, then she was asked to relax it and similarly she was one by one asked to focus on different parts of the whole body. After the session she feels little more at ease and relaxed than before. She was asked to do the same exercise before sleeping at night. • Family therapy‐ Treatment of the husband for anger management and alcoholism is to be done he has been asked to come next time.
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    Page | 78 DISCUSSION Theinternship had been a learning experience providing an opportunity to integrate theoretical knowledge, and clinical skills into practice. The training goal was to help acquire skills in clinical psychology and professional acumen under trained practitioners in the concerned setting, which was achieved. Strategies were planed and assessed during the internship helping clients and clients from different settings to overcome the problems. Also it had been a learning experience to deal with diverse population including children, adolescents and adults and learning to conduct tests and assessments making proper interpretations of the results emerging from the testing. Ten cases with case history, Mental Status Examination alongwith suggested intervensions are mentioned which were handled during the internship.
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    Page | 79 REFERENCES ƒAmerican Psychiatric Association., & American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders‐ DSM‐IV‐TR. American Psychiatric Association. ƒ American Psychiatric Association., & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders‐ DSM‐5. American Psychiatric Association ƒ Semple, David; Smyth, Roger; Burns, Jonathan; Darjee, Rajan; McIntosh, Andrew (2005), Oxford Handbook of Psychiatry, 1st Edition ƒ Kaplan, H. I., Sadock, B. J., Grebb, J. A.,(1994). Kaplan and Sadockʹs synopsis of psychiatry‐ Behavorial sciences, clinical psychiatry. 7th Edition, Baltimore‐ Williams & Wilkins ƒ Sadock, Benjamin James; Sadock, Virginia Alcott (2007), Kaplan & Sadockʹs Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition, Lippincott Williams & Wilkins ƒ Strickland, B. B. (2001). The Gale Encyclopedia of Psychology. Farminton Hills, MI‐ Gale Group.