PSYCHIATRIC HISTORY AND

M.S.E OF A CLIENT WITH

MAJOR DEPRESSIVE
DISORDER

SUBMITTED TO –

Madam Kalyani Saha

Professor SUBMITTED BY –
Apollo College of Nursing, Kolkata
Shubhrima Khan
M.Sc. Nursing 2nd year
Apollo College of Nursing, Kolkata
IDENTIFICATION DATA
Name: Rehana Parvin
Age: 22 years
Sex: Female
Father/Spouse: Sk. Rasid Parvin
Hospital Reg. No.: 936/22
Address: Vill: Banewarpur
PO: Anulia, PS: Amta
Dist - Howrah
Education: Higher secondary
Occupation: Home maker
Income: Not applicable
Marital Status: Married
Religion: Muslim
Informant: Sk. Rasid Parvin (father) and Illa Parvin (Mother)
Information: Adequate and Relevant
Date Of history taking- 04/04/2022

PRESENTING CHIEF COMPLAINT

According to patient:
Amar kichu hoini.
Amar kono bachha nei.
Ami ekhane aste chaini, maa niye eseche
Amar kotha bolte valo lagchena, maa ke jigges koro keno niye eseche.

According to Family member:

O jokhn 6 maser pregnant chilo tokhn ekbar kichuni hoyechilo  4 months ago
Kaoke chinte parchilona, vulval bokchilo  4 months ago
Tarpor hospital e vorti kora hoi, 3 din pore hospital theke chere dei, tarpor osudh kheye thik
hoye chilo  4 months ago.
Ekmas age or ekta meye hoyeche 1 month ago (2nd march 2022).
Meye hoyeche bole sasur barir lok oke r nebena boleche  2-3 weeks
Bachhar kono jotno korena, khawaiona  2-3 weeks
Bachha take dekhtei chaina  2-3 weeks
Karor sathe kotha bolena, chup chap bose thake  2 weeks
Barir baire jetei chaina, sobsomoy kise jeno voi pai  2 weeks
Eka eka kothao jete chaina, bathroom geleo sathe jete hoi  2 weeks
khawa dawa ekdom korte chaina 2 weeks
Ratre ghumaina thik kore, kintu sokale onekkhn ghumai  2 weeks

HISTORY OF PRESENT ILLNESS

Duration: 1 month
Mode of onset: Subacute
Course: Continuous
Intensity: Increasing
Precipitating Factors: Episode of seizure during 2nd trimester of pregnancy, her in laws and
husband didn’t accept her as she gave birth to a sick girl child.

Predisposing factors: Family history of suicide (grandmother), Marital conflict, history of

miscarriage, unsatisfactory relationship with in-laws, verbal assault, physically harmed by her
husband, Extramarital affair of husband.

Description of the present illness: The client was apparently well before 1 month when
she gave birth to a girl child. As the child has delayed cry as well as club foot, she was
admitted to SNCU for 7 days. As so, her in-laws refuse to accept her. After that her emotional
disturbances started. The client’s mother complaint that, for the last two weeks she neglects
her baby, refused to breastfeed the baby, didn’t want to talk to anybody, did not want to eat
anything, she is always afraid of going anywhere alone even in toilet, but the cause of fear
was not known. She also had sleep disturbances; sleep is usually decreased at night. History
reveals that, in 2018 she got married, she doesn’t have good relationship with her in-laws.
She was always verbally abused by her in-laws as she was unable to become pregnant, due to
infertility. She also has history of two miscarriage in 2019. In 2021 she became pregnant,
during pregnancy once she bitten by her husband, her in-laws blame her. It is also known that
her husband has extramarital affair. After that she went to her father’s house and stay there.
At 6 months of pregnancy the client experienced seizure episode. That time she became
hospitalized and recovered within 3 days and got discharged from hospital. 1 month ago, she
gave birth to a girl child with birth defect and in-laws refuse to accept her, after that her
abnormal behaviour started and presently, she was taken to the Pavlov Hospital by her
parents.
TREATMENT HISTORY

Drugs: Tab. Pregabalin 50 mg PO SOS

Tab. Citalopram 10 mg 1–1–x
Tab. Lorazepam 0.5 mg x–x–1
Tab. B complex
ECT- Not given
Psychotherapy: Given
Family Therapy: Given
Rehabilitation: Not given

PAST PSYCHIATRIC AND MEDICAL HISTORY

Patient was suffering from psychiatric illness for last 6 months. She doesn’t have any
previous history of hospitalization due to psychiatric illness. But during the 2 nd trimester of
pregnancy, he got admitted to the hospital due to seizure episode.
There is no significant medical history of Diabetes mallitus, Hypertension, COPD,
Hypothyroidism.

FAMILY HISTORY

There is a nuclear family in Howrah district. The patient’s grandfather was died due to stroke
before 19 years at the age of 57 years. Her grandmother was died 10 years ago in 2012 due to
suicidal attempt. The patient’s father and mother are still alive. Her father is a tailor and he is
51 years old and her mother is a home maker, 43 years old. Patient’s father is only the
earning person of the family, earning a total of around Rs. 15,000 per month. The patient’s
father has two sisters and one brother. They are married and live separately. The patient has a
younger brother, 17 years old, he is student. She had good relationship with the members of
her family. The patient got married in 2018, now she is 22 years old and her husband is a
carpenter, 27 years old. Her father-in-law and mother-in-law are still alive. Her husband has
an elder brother, who is married and lives together with his family. The patient did not have
good relationship with her in laws. Occasionally she was bitten by her husband, verbally
abused by her in-laws. That’s why she lives separately from her husband with her paternal
family.
 FAMILY GENOGRAME

70 years 62 years

Died in 2003 due to Suicide in 2012 due to

stroke family conflict

Mother, 44
Father, 51 years, home
years, tailor maker

Father-in- Mother-in-
law, 60 years law, 52 yrs

Brother,
17 years
22 years
35 years Husband,
27 years

1 month

Sl. no. Symbol Meaning

1. Male

2. Female

3. Married

4. Separated

5. Divorced

6. Index case

7. Mentally ill

8. Death
PERSONAL HISTORY

Perinatal History-
Antenatal Period- Normal
Intranatal period-
Birth- Normal delivery
Birth cry- Present
Birth defects- Nothing significant
Postnatal complications- Nothing significant

Childhood history
Primary care giver- Mother
Feeding- Breastfed
Age at weaning- 6 months
Developmental Milestones- Normal
Behavior and emotional problems- Nothing Significant
Illness during childhood: Nothing Significant

Educational History
Age at beginning of formal education: 6 years
Academic performance: Good
Extracurricular achievements, if any: Stitching
Relationships with peer and teachers: Good
School phobia: Absent
Look for conduct disorder: No
Reason for termination of study: Financial crisis

Play history
Games played (at what stage and with whom): At childhood
Relationships with playmates: Good

Emotional Problems during Adolescence: Nothing Significant

Puberty:
Age at appearance of secondary sexual characteristics: 12 years
Anxiety related to puberty changes: Anxious
Age at menarche: 13 years
Reaction to menarche: Anxious, irritable
 Regularity of cycles, duration of flow: Regular and 4 days cycle
Abnormalities, if any: Abdominal crams

Obstetrical History-
LMP: Not known
Number of children: One
Any abnormalities associated with pregnancy, delivery, puerperium: seizure
episode during 2nd trimester of pregnancy.
Termination of pregnancy, if any: No
Menopause (including any associated problems): Not applicable

Occupational History-
Age at starting work: Home maker
Jobs held in chronological order: Not applicable
Current job satisfaction: Not applicable
Whether Job is appropriate to patient’s background: Not applicable

Sexual and Marital history-

Type of marriage: Arranged
Duration of marriage: 4 Years
Interpersonal and sexual relations: Not satisfactory
Extramarital relationship if any: No

Premorbid Personality
Interpersonal relationships: introvert
Family and social relationship: Satisfactory
Use of leisure time: sewing, watching TV
Predominant Mood: Pessimistic
Usual reaction to stressful events: Normal
Attitude to self and others: Normal
Attitude to work and responsibility: Responsible
Religious beliefs and moral attitudes: She belief in God
Fantasy Life: Nothing significant
Habits
 Eating patter: Normal
 Elimination: Regular
  Sleep: Adequate
 Use of drugs, tobacco, alcohol: Nil

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE AND BEHAVIOUR

 Appearance : She looks according to her age, has average body build
and also has fair complexion.
 Facial expression : Her facial expression is anxious.
 Level of grooming : She has dressed according to situation.
 Level of cleanliness : Adequate
 Level of consciousness : Fully conscious and alert
 Behaviour : Preoccupied
 Co-operativeness : Less than normal
 Eye to Eye contact : Not maintained
 Psychomotor activity : Decreased
 Rapport : Difficult to establish
 Gesturing : Normal
 Posturing : Normal
 Other movements : Nothing significant
 Other catatonic phenomena: Not found
 Conversion and dissociative signs: Nothing significant
 Compulsive acts or rituals or habits: Nothing significant
 Hallucinatory behaviour: Nothing significant

SPEECH

 Initiation : Speaks when spoken to

 Reaction time : Normal
 Rate : Normal
 Productivity : Monosyllabic
 Volume : Decreased
 Tone : Low pitch
 Relevance : Relevant.
 Stream : Normal
 Coherence : Fully Coherent
Sample of speech:
Nurse: How far have you studied.
Patient: ‘Uchha madyamik pass korechi.

MOOD AND AFFECT

Subjective:
Nurse: How are you feeling today?
Patient: “Amar kichu valo lagchena”.
Objective: The patient looking anxious
 Predominant mood state: She has depressed mood
Inference: Affect is congruent to mood and appropriate to situation

THOUGHT

Nurse: How was your experience to become a mother?

Patient: ‘Ami janina, amar kono bachha nei’.
Inference: she had disturbances in thought formation and progression.
Content
 Delusion:
Nurse: Do you think that anybody wants to harm you?
Patient: ‘khoti to korei diyeche, r kichu khoti korte baki nei’
Nurse: Have you ever felt that some people are gossiping about you?
Patient: ‘Naa’.
Nurse: Have you felt that you are being controlled by someone?
Patient: ‘Naa’
Nurse: Do you feel that, you are only responsible for everything bad happening with you
or others?
Patient: ‘Naa’
Nurse: Do you feel that everyone is jealous about you?
Patient: ‘Naa’
Inference: Patient has delusion of persecution
 Ideas:
Nurse: Do you ever feel that your life is worthless?
Patient: “Ha sobsomy mone hoi”.
Nurse: Why?
Patient: “Amar keo nei, amar sob ses hoye geche”.
Nurse: Do you think that you would be better off dead or wish you were dead?
Patient: ‘Ha’
Inference: patient has worthless, hopelessness and suicidal ideation.

 Thought Alienation Phenomena:

Nurse: Do you think that someone is inserting though in you or withdrawing your
thought?
Patient: “Naa”
Inference: patient has no taught alienation phenomena.

 Obsessive Phenomena:
Nurse: Do you have any thought that comes to your mine repeatedly?
Patient: “Naa.”
Inference: the patient does not have any obsessional ideas.

 Phobia:
Nurse: Do you have any fearful feeling about some object or anything else?
Patient: “Ha”
Nurse: What are you afraid of?
Patient: ‘Ondhokar jaigai voi lage’
Inference: She has phobia in dark places.

PERCEPTION

Illusion: Nothing significant

Hallucination:
Nurse: Have you seen anything which has not seen by others?
Patient: “Naa.”
Nurse: Have you smelt anything which has not smelled by others?
Patient: “Naa.”
Nurse: Have you heard anything which has not heard by others?
Patient: “Naa.”
Nurse: Have you feel anything moving on your skin?
Patient: “Naa.”
Inference: No such illusion or hallucinatory behavior is found.

COGNITIVE FUNCTION

 Consciousness : Fully conscious

 Orientation :
Time:
Nurse: What time of the day it is?
Patient: ‘Sokal bela’
Place
Nurse: Where are you now?
Patient: ‘Hospital e’.
Nurse: Do you know which hospital this is?
Patient: ‘Na’
Person
Nurse: who am I?
Patient: ‘Nurse didi’
Inference: She is oriented to time place and person.

 Attention
Nurse: I will tell you few numbers, you have to repeat them after me. Say 1, 3
Patient – ‘1, 3’
Nurse: Now say 1,3, 5
Patient: ‘1, 3, 5’
Nurse: say again 1,3,5,7
Patient: ‘Parbona’
Inference: Attention is aroused with difficulty.

 Concentration
Nurse - subtract 3 from 40 and repeat 5 times?
Patient – ’37, 34, r janina valo lagchena bolte’
Inference: Concentration is distractible.
 Memory
Immediate memory: -
Nurse: I will tell you 5 words, you have to repeat them after 5 minutes: Tree, leaf,
flower, fruit, bird
Patient: ‘Gaach, pata, ful, fol, r mone nei vule gechi’
Recent memory: -
Nurse: What have you eaten last night?
Patient: ‘Vat, dal, tarkari’
Remote memory: -
Nurse- Do you remember the date of your marriage anniversary?
Patient- ‘November, 2018’
Inference- Immediate memory was impaired, Recent and Remote memory was
intact

 Intelligence
Nurse -Who is the Chief minister of West Bengal?
Patient – ‘Mamata Banerjee’
Nurse: Suppose you go to the market with 100 rupees and buy four apples with 75 rupees,
now tell me how much returns do you have with you?
Patient – ’25 taka’
Inference: her Intelligence level was good

 Abstraction
Nurse: Do you able to say one similarity between an orange and an apple?
Patient – ‘Dutoi fol’.
Nurse: What is the dissimilarity between an orange and a ball?
Patient: Lebu khawa hoi r ball diye khela kora hoi’.
Inference: Her abstract thinking ability is normal.

 Judgement
Personal:
Nurse - What you want to do at future?
Patient – ‘Janina’
Social judgement:
Nurse: What you will do if some guest will come to your house?
Patient: ‘Boste bolbo, jol khabar debo’
 Test judgement:
Nurse – What you will do seeing a baby walking towards a pool?
Patient – ‘Okhan theke soriye anbo’
Inference: Her personal, social and test judgement were intact.

INSIGHT
Nurse: Why are you come to this hospital?
Patient: ‘Ami janina, maa jane’
Inference – She has no emotional insight about her illness. Insight level 1.

DIAGNOSTIC FORMULATION

Patient was apparently alright at childhood and adolescent period; she was good in study. in
spite of this she discontinued her study due financial crisis. She belongs to a nuclear family.
There is a suicidal history in her family. She always had good relationship with friend and
family member. She was responsible and good at house hold work. But she always possesses
an introvert personality. Regarding marital history, she got married at 18 years of age, but she
had marital conflict and family issues due to infertility. She does not have good relationship
with her in laws, she always faced verbal assault and abusive languages from her husband
and in-laws. Her obstetrical history showed that she had infertility and had history of two
miscarriage, she experienced a seizure episode during 2nd trimer of pregnancy. Her
psychological problems were started before 1 month, after her child birth. As she gives birth
to a girl child with birth defect, she was rejected by husband and in-laws. Now for last two
weeks she denied the fact that she has a child, refuses to take care of her baby, has social
withdrawal, does not want to talk to anybody, she also has anxiety, irritability, phobia,
insomnia, excessive day time sleeping, weakness, loss of appetite, inability to perform her
own activities. Mental status examination revealed that she has poor attention and
concentration, impaired immediate memory, disturbances in thought, has hopelessness,
worthlessness and suicidal ideation, poor personal judgement, and has no insight about her
illness. According to ICD 10 her present problems are similar to the symptoms of major
depressive episode and she was diagnosed with Major depressive disorder by Psychiatrist.