The patient is a 45-year-old married female who has been experiencing psychiatric symptoms for 12 years. She initially presented with fear, talking to herself, and suspicious behavior. Medications provided minimal relief and her condition has worsened over time. She now experiences auditory hallucinations, delusions that she is being harassed, and shows unpredictable and aggressive behavior. A mental status examination revealed impaired thought processes and insight.

1. Case presentation
Dr.Arunitha .R
2nd Year PG Scholar
Dept of Kayachikitsa
Govt.Ayurveda College,
Thiruvananthapuram

2. PATIENT DATA
Name - Bindhu. Ward-FGW
Age - 45 Bed No-42
Sex - Female DOA-22/2/19
Marietal Status - Married DOD-04/03/19
Religion- Hindu Attending physician-Dr.Subhash Babu
Economic status -middle class Informants-patient,mother
Address kavinpurathuveedu Case taken on-01/03/2019
Taruvamood
Neyyattinkara
Phone No-8129740818(Husband)

3. According to patient,
Two or more persons are dwelling inside and
controlling her-12 years, since 6 month
According to mother,
Self talking
Self laughing 12 years since 6 month
Suspicious
Odd behaviour

4. History of presenting complaints
According to informant,
Patient was apparently normal and mentally sound before 12
years.
The complaints started 12 years back when patient was at
the age of 34 year .She is married and having two sons.Her
husband was working abroad during the time when her
complaints started.
Due to some issues in the job site,her husband couldnot
maintained any relation ship with her.She stayed with her
sons near to her own family .she was anxious and worried
about her relationship issues.Family expenditure was carried
out by her father.
Mother reported that symptoms developed as sudden onset
before 12 years.One morning she appeared and acted
extremely frightened.Her facial expression was fearful.She
responded violently towards all the attempt made by her
mother to console her.She constantly did irrelevant talks
like,someone is trying to kill her and the people surrounded

5. Her appearance was with staring wide eyes,flushed
face,clenched teeth and forceful breathing with increased
sweating.
They approached nearby GH where she was evaluated and
treated with antipsychotics medicines .In hospital she was
very uncoperative and aggressive.
She got discharged then and advised to take medicines for
one month. During the course of medications she found to
be extreme drowsy ,reluctant to get out of bed.she loss
interests and pleasure in her usual activities.she refused to
take food and drinks . But still she maintained good personal
hygeine.
Patient became socially withdrawn with no interest in her
own or family matters .She also lack emotions and fail to
sustain relationship.

6. Patient continued prescribed medicines regularly but did not
found any significant improvement . Few years thereafter she
resist to continue the treatment ,arguing that there is nothing
wrong with her and those medications can cause harm to
her.
Thereafter she became increasingly odd in
behaviour.According to patient two or more persons are
dwelling inside her and she can hear the voices.It is coming
either inside or outside her head may be male or female,and
is not recognised as familier. Content of what the voice are
usually unpleasant and negative.Sometimes the voices are
conversing or commanding.The patient has been unpredictable
and responding to internal stimuli and cursing them.She believing
that she is being harrased or bodily injured by others and they
removed her energy and bodyparts.

7. Now a days she is becoming aggressive without
any significant provocation.She is fighting with
them and so she is in constant stress.She believes
that she is being followed by somebody ,so
become unreasonably suspicious of others.She
occasionally agitated towards family members and
after that she did not remember anything related to
it.Mother also reported self talking ,self laughing
along with odd behaviour

8. HISTORY OF PAST ILLNESS
Medical history
No significant past illness
Psychiatric history
No history of psychiatric illness.
Past surgical history-nil

9. DRUG HISTORY
Tab. Lanitor 100mg. 0-0-1 since 6months.
Tab. Quetiapine 25mg. 0-0-1
Tab. Brupronyl 150mg. 1-0-0

10. Family History
H/o HTN
DM2,CVA. DLP
Died @68
22 years
Bike accident @21yrs
Family Psychiatric History –Unremarkable.

11. Family problem-relation with husband
unsatisfactory
Nuclear family…
No family breakup…
Death of immediate family members (+)
Son died before 5 years
No suicidal attempt in family.
No H/0 epilepsy/major medical illness.

12. PERSONAL AND SOCIAL HISTORY
Childhood history
DOB-10/1/1974
Uneventful birth history.
Anti-natal/Natal/post-natal-Uneventful
According to mother she doesn’t suffer any
healthproblem in her earlyage.
No history of maternal deprivation
Early emotional stress –emotionally sound
Childhood neurotic syndrome-absent

13. Educational history
Age of schooling -5years
Below average student
No extra curricular activities
Marks scored in sslc –just passed
Maintain good relation ship with peers and teachers.
No history of trouble or difficulty at school.
Qualifications achieved-pre-degree.

14. Occupational History
Worked in computer centre as assistant
for 2 years.
Then discontinued the job
Reason unknown…….

15. Marital history
Arranged marriage with her consent….
Marriage @18 years
Age of spouse-25 years,
Duration of marriage-27years
Relationship with spouse-unsatisfactory

16. Sexual history
No history of sexual abuse.
No history of premarietal or
extramarietal relationship.
Patient not at all willing to reveal her
sexual history.

17. Menstrual and obstetric history
Menarche-14 years
Regular cycle
Duration -5-6 days
LMP-February 20, 2019
No associated abnormalities
Obstetric history
First delivery @20 years
Second delivery @24 years
Normal delivery.
No history of abortion.

18. DIETRY HABITS
Wake up –Irregular timings
No exercise/routine daily activities
Breakfast -@ irregular time
usually dosha(2)/puttu/idly(3)/chappathi(2)/uppuma/
poratta (2)occasionly
+chutny/sambar/vegetable curry
Lunch –usually @3.00pm
rice+avial/thoran/sambar/moru/parippu/fish/almost
daily non –veg(meat)

19. Tea @6.oopm with snacks(biscuit/vada/any
bakery food items)
Dinner@10.00pm –rice +menu of lunch.
Sleep-no specific time
Daily non-veg diet
fishfry/pickles/curd/bakery
food items
Taste predominance of
sour,pungent,
Irregular food habits.

20. Appetite Often increases or decreases.
Bowel- once/day(well-formed stool)
Bladder 3/4 times per day
No associated complaints.
Sleep sleeplessness present since 6
month,difficulty in initiation
of sleep
Disturbed sleep(+)
Allergy nil
Addictions nil

21. Premorbid personality
Interpersonal relationship keeping good relationship with
family members and friends
Leisure time Household activities
Predominant mood Stable,no mood swings.
Normal way of
expressing anger
Attitude to self and others Thoughtful
of others
Fantasy of life Absent
Religious beliefs Believer

22. GENERAL EXAMINATION
Appearance-Conscious,oriented
Moderatebuilt,moderate
nourished,well groomed.
Height -164cm
Weight-75kg
BMI-27.9kg/m

23. Pallor
Icterus
Cyanosis NIL
Oedema
Clubbing
Lymphadenopathy

24. VITALS
Bloodpressure - 130/80mmHg
Pulse rate - 80/min
Regular ,normal volume
Heart rate - 80/min,Regular
Respiratory rate - 20/min
Temperature - Afebrile

25. Physical examination
Head and neck
Thorax and abdomen
NAD
Upperlimbs
Lowerlimbs

26. SYSTEM review
Cardiovascular No H/o chestpain/DOE/increased palpitations
Respiratory system No cough/respiratory problems
Gastro intestinal system Appetite-irregular,no abdominal pain/heartburn
Nervous system No H/o paresthesia/weakness
Integumentary system No visible skin lesions
Genito urinary systems NAD
Locomotory system- pain(+) all over body .
(Pins and needle sensation)

27. Mental status examination
1-General appearance
45 year old women,appear as her age is.
Well built,moderately nourished.
Looks normal.
Patient grooming was fair after morning
care.Most of the time she exhibited
appropriate facial expressions and posture
during interactions ,maintain good eye
contacts.

28. Attitude co-operative
Facies Appropriate ,sometimes
anxious,and shows
irritation.
Gait Normal
Posture Normal
Psychomotor activity Appropriate
Rapport Easily established

29. 2.Speech
She consumes only minimal time and effort in answering
which is fairly clear and understandable,but difficult to
follow because sequence of thoughts follows a logic to
patient but not to others.
Rate- Rapid
Speech is present which is spontaneus with normal rate
Volume -Normal volume with normal pitch
No hesistant or no stammering.

30. 3.Mood and Affect
Affect-Appropriate
Mood - Varying moods from being
happy,sad,irritable.

31. 4.Thought
Patient express variety of odd beliefs.
Stream and form-Impaired
Spontainity+
Flight of ideas+
Thought blocking+
Illogical thinking +

32. 5.Perception
Delusion-present
Hallucinations-Auditory
(2nd person)
Patient admit to hallucinations or
respond to auditory stimuli.

33. 6.Cognition
a)Attention –normal
b)concentration-slightly impaired
She couldnot focus and participate well during the
examination as she is easily distracted by almost
everything.
c)Memory
Remote
Recent
Immediate Intact
d)Intelligence-subnormal
e)Abstract Thinking
Patient is not fully capable of performing
abstractions or conclusive evaluating questions.

34. 7.Insight
Impaired
Clinical rating of insight –Grade 3
(Awareness of being sick,but it is
attributed to external or physical factors)

35. 8.Judgment
Basic judgment is normal .

36. Schizophrenia-At a glance
One of the most disabling and emotionally
devastating illnesses known…
Extremely complex mental disorders…….

37. History
First identified in 1887
Term coined in 1911 by Eugen Bleuler
Schizo +phrenia
(split)+(mind)=fragmented thinking.

38. The schizophrenic disorders are
characterized in general by fundamental
and characteristic distortions of thinking
and perception,and affects that they are
inappropriate or blunted.
Clear consciousness and intellectual
capacity are usually maintained although
certain cognitive deficits may evolve in the
course of time

39. Causes
Genetics
Development factors
Substance abuse
Brain chemical imbalance

41. Types
Paranoid type
Hebephrenic
Catatonic type
Undifferentiated type
Residual type
The ICD-10 defines additional subtypes
Post-schizophrenic depression
Simple schizophrenia

42. Symptoms
Positive/hard symptoms
Delusion
Hallucination
Grossly disorganised
thinking,speech,behaviour
Negative/soft symptoms
Flat affect
Lack of volition
Social withdrawal or discomfort

43. Diagnosis
The DSM 5 outlines the following criterion to make a
diagnosis of schizophrenia:
Two or more of the following for at least a one-month (or
longer) period of time, and at least one of 1,2,3.
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms, such as diminished
emotional expression

44. Impairment in one of the major areas of
functioning for a significant period of time
from the onset of the disturbance: Work,
interpersonal relations, or self-care.
Some signs of the disorder must last for a
continuous period of at least 6 months.
Schizoaffective disorder and bipolar or
depressive disorder with psychotic features
have been ruled out:

45. First Rank Symptoms of
schizophrenia(SFRS)
Audible thought +
Voices heard arguing+
voices commenting ones action+
Thought insertion+
Made volition or acts+
Somatic passivity+
Delusional perception+

46. Suggested investigations
Thyroid function test
Brain CT,MRI.

47. PROVISIONAL DIAGNOSIS
SCHIZOPHRENIA

48. Differential diagnosis
Schizoaffective disorder
Delusional disorders.
Mood disorders.

49. DIAGNOSIS
SCHIZOPHRENIA

50. Modern management
Pharmacological management
Psycological management
Rehabilitation
Family work
Other physical management

51. AYURVEDIC CLINICAL ASSESsMENT
A)Rogi pareeksha
Dasavidha pareeksha
Assesment of Dooshya
1)Dosha
Saririka dosha vata(bhaya,soka,chinta)
pitta(krodha,alpanidrata)
Manasika dosha rajas ,tamas
2)Dhatu rasa

53. Rogabala(pravara)
Assessment of Bala
Rogibala(avara)

54. Assessment of Kala
ksanadi Greeshma
vyadhyavasta purana

55. Assessment of anala vishama
Assessement of prakrithi
Saririkaprakruthi kapha ,vata
Manasa prakruthi tamopradhanam
Assessment of vaya madhyamam
Assessment of satmya madhyamam

56. Assessment of Aharasakti
Jarana sakti madhyamam
Abhyavaharanasakthi avaram

57. Assessment of manovaha srotas
1.Manas
Indriyabhigraha grossly impaired
Manonigraham impaired
Ooham normal
Vichara normal

58. 2.Budhi impaired
3.Samnjananam
orientation to place,date
person-intact
Attention ,concentration –slightly impaired
4.Smrithi intact

59. 5.Bhakti (desire)
Ahara normal
Vyavaya
Vesa
ranjanam

60. 6.Seela
Diet-occasional dislike towards food.
Sleep-disturbed
No addictions/drug abuse
Daily routine activities impaired..
7.Chesta
General motor activities
Speech
Facial expression normal
posture

61. 8.Achara
Personal standards impaired
social standards impaired
No obsessions in work
Habit of cleanliness (+)

62. Roga pareeksha
Nidana
Ahara
Teekshnahara(pickles),
katuamlarasapradhana,gurvahara(curd,meat)
Snidha ahara(bakery foods,fried food)
Vishama ahara vidhi-
pramithabhojana,adhysana
Vihara –nisa jagarana

63. Manasika bhaya,soka,chinta

64. Roopam - ekatra hasati
ekatra rodati
alpahara
anidra
anannabhilasha
atichesta

65. Samprapthi
Due to nidana sareerika
doshas(vata,kapha)vitiated
Trigunas of manas got dearranged(avara satva)
satwa rajas tamas affect
manovahasrotas
manovikaras

66. Sapeksha roga nirnayam vatika unmada/
Vyavachedaka roganirnayam
pittaja,sannipathika unmadam
Atatvabhinivesam
Apasmaram

67. ROGA NIRNAYAM
VATIKA UNMADAM

68. Chikitsa
Yuktivyapasraya chikitsa
Sattvajaya chikitsa
Daivavyapasraya chikitsa

69. Chikitsa sutra
Virechanam
Deepanam
snehapanam
Sirodhara
Nasya

70. Virechanam with avipathichoornam-40gm morning
withmadhu
Deepana with
Aswagandharishtam+panchakolachooram(5g)for 3 days
Snehapanam with mahakalyanakaghrita starting with
50ml upto maximum dose.
Abhyngam+usmaswedam for threedays with sarsapa
tailam

71. Sirodhara with chandanadi tailam for 7 days
Nasyam +thalam for 3 days
Nasya with anutailam
Thalam with ksheerabala +panchagandhachooram
As rasayana
Aswagandha choornam with milk bedtime

72. Kasaya yogas
Drakshadi kasayam
Brahmee drakshadi
Kalyanaka kashayam
Choornas
Sankupushpi choornam
Aswagandha choornam
Jadamamsi choornam
Yasti choornam

73. Gulika
Manasamitra vatakam
Ghritam
Brahmighrtam
Mahakalyanaka ghrtam
Kayanaka ghrtam
Paisachika ghrtam