INTERNSHIP REPORT

(December 2021)
In partial fulfilment of the requirements for the award of the Master
of Arts Degree in Psychology

Submitted By
MUHSINA P
Enrolment No.:185195117
Regional Centre: Vatakara (83)

Under the guidance of

Shri. REEMA UMMER

At
PROGRAM CODE: MAPC

MPCE 025: Internship in Counselling Psychology

INDIRA GANDHI NATIONAL OPEN UNIVERSITY

Mobile no: 8281928349 email: muhsina8281@gmail.com

1
 DECLARATION

I Mrs. MUHSINA P, hereby declare that I am a Learner of M.A. Psychology (Part II), July
2018 year, at the Study Centre Code 1403 Regional Centre 83 and I want to do my Internship
(MPCE-025) a PSYCHE CARE, on my own free will. I will adhere to the standards of the
organization and display professionalism during my internship.

Signature of the Learner

Name of the Learner: MUHSINA P Date:
Enrolment No.: Place: Kizhisseri

2
 CONSENT LETTER (Agency Supervisor)

This is to certify that the internship in MPCE-025 for the partial fulfilment of MAPC Programme
of IGNOU will be carried out by Mrs. MUHSINA P under my supervision.

(Signature)
Name of the Agency Supervisor: Mrs. REEMA UMMER
Designation: clinical psychologist,

Name of organization:
Address:

Date:

3
 CERTIFICATE

This is to certify that Mrs. MUHSINA P of M A Psychology Second Year (MAPC Programme)
has conducted and successfully completed the Internship in MPCE 025 in PSYCHE CARE,
MUNDAKKULAM.

Name: Muhsina P Name:

Enrollment No.: Designation:
Name of the Study Centre: JDT Islam Place:
Regional Centre: Vatakara Date:
Place: Kizhisseri Date:

Signature of Agency Supervisor

Name: Mrs. REEMA UMMER
Designation: clinical psychologist, program director
Name of the Organization: psyche care Address:
Place:
Date :

4
 APPENDIX-IVRECORD OF VISITS/ACTIVITIES CARRIED BY
LEARNER
Sl Date Topic Resource Person Hours
NO

1 10-12-2022 Course Orientation Case Reema Ummer , 10:30am

History Taking Consultant psychologist to 12pm

2 12-12-2022 Mental Status Examination Jincy Raj Clinical 10:30am

psychologist to 12pm

3 14-12-2022 Learning Disability and Reema Ummer , 10:30am

Assessment Consultant psychologist to 12pm

4 16-12-2022 Introduction to ICD and Hanan.k.k, Councellor 10:30am

DSM to 12pm

5 19-12-2022 Psychological Assessment Jincy Raj Clinical 10:30am

and Test psychologist to 12pm

6 20-12-2022 Case Discussion Reema Ummer , 10:30am

Consultant psychologist to 12pm
7 22-12-2022 Childhood and Adolescent Jincy Raj Clinical 10:30am
Disorders psychologist to 12pm

8 23-12-2022 Basic Skills and Techniques Jincy Raj Clinical 10:30am

in Counselling psychologist to 12pm

9 24-12-2022 CBT Reema Ummer , 10:30am

Consultant psychologist to 12pm

10 26-12-2022 DBT Reema Ummer , 10:30am

Consultant psychologist to 12pm

11 29-12-2022 Psychoanalysis and SFBT Hanan.k.k, Councellor 10:30am

to 12pm

12 30-12-2022 Case Discussion (Adult) & Reema Ummer , 10:30am

Conclusion Consultant psychologist to 12pm

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 OBJECTIVES OF THE PRACTICUM

Internship in clinical psychology is a one year of supervised training in a clinical facility

including diagnosis, therapy, research, seminars and conferences required to fulfill the Ph. D.
degree.

- Dictionary of behavioural science (1973)

For MA in psychology, the concept has been adapted into a short version as

‘practicum in clinical psychology’.

The main objectives of the practicum are as follows:

• Provide comprehensive training to the learners

• Help learners develop skills and techniques to provide the needed services to

individuals, groups and organizations

• Develop professional competence amongst the learners; and

• Encourage learners to maintain the highest standards in offering services to

individuals, groups and organizations;

With these objectives, we spent a period of 30 days which covered 90 hours in total (online and
offline), according to the guidelines issued by IGNOU to carry out our online internship
program, considering the present pandemic situation.

INDEX
TITLE PAGE NO.

6
 Objectives 6

Profile of the institution 8

Introduction 10

Case-A 17

Case-B 21

Case-C 25

Case-D 30

Case-E 36

Case-F 40

Case-G 45

Case-H 50

Case-I 55

Case-J 61

Conclusion 68

Reference 69

PROFILE OF INSTITUTION

Psyche Care Counselling Centre & Educational Institution

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Psyche Care Counselling Centre and Educational Institution established at Mundakkulam
, Malappuram in 2022. Psyche Care Centre is also an educational institution for psychology
students and established with the view of psycho-social empowerment of the society. Psyche
care counselling centre is a private centre. Psyche care counselling centre has been providing
counselling and psychotherapies for various psychological problems ie. Behavioural issues ,
academic problems , adolescent issues , family issues , addictive behaviours , emotional
problems and neurotic problems.

Psyche Care Counselling Centre is private institution for psycho-social empowerment and
study centre for psychological aspects , situated in above the KSEB office , 2 nd flour ,
Mundakkulam , Muthuvallur (p.o) , Kondotty – Edavannappara road of Malappuram Dt.

Psyche Care Counselling Centre and Educational Institution is aimed for different activities ,
projects like , internship providing , contact classes for psychology students , PPTTC and
MTTC etc. During the short period of time , it has been proved the sincere and collective efforts
to promote mental health and well-being . The interventional programs of Psyche care is
focusing of students , youth , parents , employer , children and proffesionals through
implementing various training activities like camp , awareness program , competition etc.

Facilities

The psychology department is headed by an consultant psychologist and there are faculties like
counsellors , trainees etc..

Faculties of the department

1. Mrs. Reema Ummer , Msc. Psy.DRE(consultant psychologists , child Remediator)

2. Jincy Raj , Msc Psy.(Psychologists)
3. Hanan , k,k , Msc Psy(counsellor)

4. Sherin .k p Msc Psy(Trainee)

Extention activity

Psyche care counselling centre and educational institution contuct 10 days camp for backward
students , drawing competitions for children , online remediation programs .

8
Internship

Psyche care counselling centre provides 30 days of internship programme for UG/PG
psychology students that include MSE. Initial case taking , psychological assessments ,
introduction to counselling and psychotherapy .

Introduction

1.1 FIELD WORK

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Field work is an exciting opportunity to consolidate academic learning with clinical learning
and develop professional behaviours and competencies. It gives an understanding of therapy
practice in a variety of settings. Throughout the fieldwork experience students are given a broad
range of learning opportunitites, working with clients across the lifespan and across the health
care continuum, in the areas of both psychosocial and physical health.

The fieldwork practicum is the central mechanism for transmitting theoretical knowledge into
the practical level of work (Sherer & Peleg-Oren, 2005). While classroom learning focuses on
discrete knowledge and theoretical background, the field work practicum exposes students to
wide range of problems and possibilities.

For students in psychology discipline, it is important for them to gain practical knowledge and
experience in handling and understanding different disorders and illness people face before
their career begins. Field work can provide a student more exposure and a deeper understanding
about the disorders than a book or lecture can. The clinical presentation or the practical reality
is much different from what is being given in the DSM or ICD or the books. During a field
work or clinical practice, a student leans case history taking, report writing, evaluation, psycho
education, usage of different therapies and interacting with the patient and their family. It is
often difficult to make the patient or the family to be comfortable and to open up. It is important
to build rapport and faith among them also to destigmatise about the counselling or treatment.
The family and the patient should be given psycho education on the treatment and medications
and other areas. Field work provides a lot of exposure to the student over all these areas and
they come out of the clinic after getting some experience.

1.2 CASE HISTORY

“A record of information relating to a person’s psychological or medical condition used as an

aid to diagnosis and treatment, a case history usually contains test results, interviews,
professional evaluations, and sociological, occupational and educational data , also called patient
history.’’ A case history basically refers to a file containing relevant information pertaining to
an individual client or group. Case histories are maintained by a broad range of professional
organizations including those in the fields of psychiatry, psychology, healthcare and social work.

The major purpose of initial interview is to obtain information that will help to establish a
criteria-based diagnosis. This diagnosis is useful not only in identifying and labeling the

10
patients problems by also in predicting the course of the illness, the prognosis and the ensuing
treatment decisions. A well-conducted psychiatric interview results in the understanding of the
bio-psychosocial aspects of the disorder and provides the information necessary to develop an
individualized treatment plan.

Elements of case history taking

The patient history is based on the subjective report of the patient and in some cases, the report
of additional sources, including othert health care providers, family members and other
caregivers. Chief components of the history should include:

Socio demographic data

Name, age, sex, marital status, religion, address, occupation, education Presenting complaints

The presenting symptoms and its durations

In patients own words
Informant complaint (reliable informant)
History of presenting illness
Onset, duration of illness
Nature and causal factors, development of symptoms and relation of
Events, stressors Impact of illness; change from previous level of functioning
Past history
Includes both psychiatric and medical, neurological illnesses Previous
hospitalization and their duration and level of improvement,
medication taken with the reported response and compliance
Family history
Psychiatric history and medical histories
Name, age, occupation of the family members. Order of birth of the patient and the relationships
between the family members as reported by the patients.

Personal history
Developmental history, prenatal, natal and postnatal
Childhood
Adolescence

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Adulthood
Psycho-sexual history
Work history, marital history, children, level of education, finance, legal history
Substance use/abuse and addictions
Premorbid personality
Nature, affect, relationship, attitude of the person toward people, religion, before
the illness.

Mental status examination

A Mental Status Examination is an assessment of a patient's level of cognitive
(knowledgerelated) ability, appearance, emotional mood, and speech and thought patterns at
the time of evaluation. It is one part of a full neurologic (nervous system) examination and
includes the examiner's observations about the patient's attitude and cooperativeness as well as
the patient's answers to specific questions.

The purpose of MSE is to assess the presence and extent of a person's mental impairment. The
cognitive functions that are measured during the MSE include the person's sense of time, sense
of place, and personal identity; memory; speech; general intellectual level ; mathematical
ability; insight or judgement; and reasoning or problem-solving ability.

The MSE is an important part of the differential diagnosis of dementia and other psychiatric
symptoms or disorders. The MSE results may suggest specific areas for further testing or
specific types of required tests. MSE can also be given repeatedly to monitor or document
changes in a patient's condition.

The MSE cannot be given to a patient who

• Cannot pay attention to the examiner, for example as a result being in a coma
or being unconscious; or

• Is completely unable to speak (aphasic); or

• Is not fluent in the language of the examiner.

The history and Mental Status Examination are the most important diagnostic tools to make an
accurate diagnosis. Although these important tools have been standardised in their own right,
they remain primarily subjective measures that begin the moment the patient enters the
psychologist's room.

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Elements of mental status examination

• General appearance, grooming, gait, posture, facial expression

• Level of activity, retarded, agitated , tics, tremors 6

• Attitude, cooperative, hostile, eye to eye contact

• Level of consciousness, orientation to time, place and person, attention and

concentration

• Memory; immediate, recent, remote

• Mood; patient’s expression of his own feeling (subjective description)

• Affect ; Examiner’s expression of the patient’s feeling and its appropriateness to the
situation (objective description)
• Speech; Description of the patient’s speech, slow, fast, spontaneous, slurred
• Thought examination
Form – off pointing, thought block, tangential, circumstantial, loose association,
neologism, incoherence. Stream – fast, pressure of thoughts, flights
Content – delusions, obsessions, phobias
Control – broadcasting, insertion, withdrawal, reading Abstraction and judgement

• Perceptual examination
Illusions: misinterpretation of stimulus
Hallucination; perception with no stimulus

Cognitive functions; conceptual thinking

Examine; type (visual, gustatory, olfactory, tactile or auditory), timing, content,
frequency and reaction of the patient

• Insight
Insight for illness, symptoms, need for treatment and compliance.

• Provisional diagnosis and treatments

1.3 DSM

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In 1918, the American Medico-Psychological Association (presently the American
Psychological Association or APA) issued the Statistical Manual for Use of Institutions for the
Insane. It did not catch on. In 1928, the American Psychiatric Association issued another
edition but it was too narrowly focused. It looked primarily at neurosis and psychosis. By
World War II, the military had its own nomenclature system. The World Health Organization
(WHO) issued the International Classification of Diseases -6 (ICD-6); it contained a section on
mental disorders but it needed modification for use in the United States.

DSM I:

The APA published the Diagnostic and Statistical Manual of Mental Disorders in 1952; it was
based off of the ICD-6 and the military system. The first DSM contained about 60 disorders
and was based on theories of abnormal psychology and psychopathology. DSM was criticized
for its reliability and validity. The major limitation of the DSM was that the concept had not
been scientifically tested. Also, all of the disorders listed were considered to be reactions to
events occurring in an individual’s environment. Another problem was that there really was no
distinction between abnormal and normal behavior. Despite this, it gained acceptance.

DSM- II

The DSM- II was published in 1968. Changes in the DSM-II included eleven major diagnostic
categories, with 185 total diagnoses for mental disorders. Additionally, increased attention was
given to children and adolescents in the DSM-II. In 1947, the DSM-II no longer listed
homosexuality as a disorder.

1.4 ICD

The ICD is the foundation for the identification of health trends and statistics globally. It is the
international standard for defining and reporting diseases and health conditions. It allows the
world to compare and share health information using a common language.

14
The ICD defines the universe of diseases, disorders, injuries and other related health conditions.
These entities are listed in a comprehensive way so that everything is covered. It organizes
information into standard groupings of diseases, which allows for:

• Easy storage, retrieval and analysis of health information for

Evidence based decision making;

• Sharing and comparing health information between hospitals, regions, settings and
countries; and

• Data comparisons in the same location across different time periods.

It is the diagnostic classification standard for all clinical and research purposes. These include
monitoring of the incidence and prevalence of diseases, observing reimbursements and
resource allocation trends, and keeping track of safety and quality guidelines. ICD allows the
counting of deaths as well as diseases, injuries, symptoms, reasons for encounter, factors that
influence health status, and external causes of disease.

The first international classification edition, known as the International List of Causes of Death,
was adopted by the International Statistical Institute in1893. The ICD has been revised and
published in a series of editions to reflect advances in health and medical science over time.

WHO was entrusted with the ICD at its creation in 1948 and published the 6th version, ICD-6,
that incorporated morbidity for the first time. The WHO Nomenclature Regulations, adopted
in 1967, stipulated that Member States use the most current ICD revision for mortality and
morbidity statistics.

ICD 10 was endorsed in May 1990 by the Forty-third World Health Assembly. It is cited in more
than 20,000 scientific articles and used by more than 100 countries around the world.

15
ICD-11was released in 18 June 2018, for Member states to prepare for implementation,
including translating ICD into their national languages. ICD 11 was submitted to the 144th
Executive Board Meeting in January 2019 and the 72nd World Health Assembly in May 2019
and following the endorsement, Member States will start reporting using ICD 11 from January
1st of 2022.

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 CASE STUDY A

SOCIO-DEMOGRAPHIC DATA

Socio demographic details

Name: A

Age: 6 year

Gender: male

Education: UKG

Religion: Islam

Language: Malayalam

Residential area: rural

Socio economic status: middle class

Informant: mother

Information: the information was provided by client’s mother, hence

The information was reliable and adequate.

CHIEF COMPLINTS

• Lack of sitting, irritability

• Can’t pay attention

• Sleeping at classroom

• Talk in between

• Changes in left and right sides of shoes (since 8 m)

HISTORY OF PRESENT ILLNESS

A is a 5 year old UKG student who live with parents. He is only child these parents .He is very
intelligent and very well performance in Academic. He is very talented student in his class
room. The complaints that the boy doing work very quick but doesn’t complete. Also working

17
multiple tasks but do not complete .He is very alert and vigilance &very curious to know novel
thinks. But he can’t sit any work or task more than 5minuts. The poor Attention distractibility,
hyper activity, impulsiveness, are main issues at this boy.

HISTORY OF PAST ILLNESS

There is no history of Organicity and sensory perceptual disturbance, there was no history
suggestive influence his thought, there is no history of persist to pervasive Elevate mood.

EDUCATIONAL HISTORY

The boy is good performance in academic continuing education in UKG standard. No

disciplinary issues reported by teachers .the hyper active in class work has reported.

FAMILY HISTORY

The patient is the only one child of Non consanguineous marriage .no psychiatric illness physical
illness among 2 gene relation reported.

PERSONAL HISTORY

The patient mode of delivery was normal ,the developmental milestones are age appropriate ,
current functional status, fine motor function, sensory function ,Expressive communication are
intact and completely .

MENTAL EXAMINATION STATUS

General appearance: The patient was well kempt, conscious, oriented, and eye to eye contact
was maintained rapport was not established.

18
Mood and affect found to be Euphoric.

Psycho motor activity: The patient psycho motor activity was adequate and speech was
normal, audible, and coherent.

Cognitive function: the patient is conscious, oriented, know place, date, and Time person.
The attention and concentration is aroused but not sustained.

Memory: the patient immediate memory, recent memory, remote memory are not intact and
delayed.

Intelligence: the intelligence of patient was above average IQ.

Thinking: is abstract, judgement is persons satisfactory.

Insight: level is 4

The test was done by letter cancellation, Wechsler intelligence performance test are satisfactory
level. There were no evidence formal thought disorder also perception delusions.

DIAGNOSTIC FORMULATION

The done by the test letter cancelation for attention /Concentration .the IQ test by Wechsler
children intelligence test .The patient was UKG student came from single family with the
complaints of hyperactivity, impulsiveness, distractibility, poor attention. The boy was very
alert and talkative, very well performance in academic. There is no history of organicity
perceptual disturbance, reported by the patient. Also no history of pervasive mood evaluated
the patient is the only one child of his parents .The family history of this patient no suggestive
psychiatric and physical illness among 2 generation. The patient was above average
intelligence .the patient was well kempt, conscious, oriented, and eye to eye contact was
maintained. Psychomotor activating was adequate and speech was normal there was no formal
thought disorder. No content the mood affect was euphoric .the cognitive process we oriented
the memory not intuit become delay. The attest on is aroused bot not sustained. The intelligence
was above average.

PROVISIONAL DIAGNOSIS

19
ICD 10 F90.9 ATTENTION DEFICIT HYPERACTIVITY DISORDER (MILD)

TRATMENT PLAN

• Social skill training

• Behaviour therapy

• Parent skill training

20
 CASE STUDY B

SOCIO-DEMOGRAPHIC DATA

Socio demographic details

Name: B

Age: 53 year

Gender: female

Education: 10

Religion: Islam

Language: Malayalam

Occupation: Nil

Marital status: Married

Socio economic status: middle class

21
Informant: sister

Information: reliable and adequate.

CHEIF COMPLAINTS

• Lack of sleep
• Speak irrelevant things
• Increased speak
• Speak faster
• Do more prayer activities
• Reduced appetite
• Angry towards others
• Onset : acute
• Duration : 30 years
• Course: discontinuous

HISTORY OF PRESENT ILLNESS

The patient was symptomatic 4 times in 30 years. There was a change in her behaviour. She
was worried about her daughter, when she leave her about 15 days for umrah. She had a history
of bipolar 1 disorder (manic episodes) 3 years ago. Presently she has sleep problems and she
talk irrelevant things. Recently she is angry towards others, speak faster and do more prayer
activities.

HISTORY OF PAST ILLNESS

Psychiatric illness: bipolar 1

Medical significant: medicine takes for sleep and bipolar 1. Drug

use: sleeping pills, lithium carbonate sustained release tablets.

FAMILY HISTORY

22
She has father and mother. She has 3 brothers and 4 sisters. There is no history of psychiatric
illness in her family. She has a good relation with her family.

PERSONAL HISTORY
Prenatal and perinatal history: she had no proper nutrition in one year old.
CHILDHOOD HISTORY
Early childhood: details were unknown
Middle childhood: started to go school at the age of 5 years.
Scholastic history: she was an average student, active in extracurricular activities and she has
completed her 10th grade.

OCCUPATIONAL HISTORY
Unemployed
PREMORBIDAL PERSONALITY
Interpersonal relationship: she is an extrovert person keeping good relation with family
members and others.

Predominant mood: anger

ATTITUDE SELF AND OTHERS
She was concerned about her family members.
Hobbies: reading, cooking

Fantasies and dreams: she didn’t report any dreams and fantasies.

MENTAL STATUS EXAMINATION

General Appearance: patient was tidy, not maintained eye contact and irritable.
Attitude towards the examiner: Not good attitude throughout the session.
Speech characteristics: increased volume, rapid and pressured speech.
Mood and affect:

23
Subjectively: “I’ am ok”
Objectively: Angry and irritable
Patient displayed inappropriate and constricted affect.

The patient mood was incongruent. Thought:

• Stream and form of thought: flight of ideas
• Possessions: thought blocking
• Thought content: she was experienced increased suspiciousness
• Perception: visual hallucinations, derealisation, grandiose.

Sensorium and cognition

Consciousness: she was not conscious about the environment.
Orientation: she was not oriented to time, place and person.

Memory
Immediate memory:
Immediate digit span forward: 2
Immediate digit span backward: 2
Recent memory: impaired
Remote memory: intact
Attention: impaired
Concentration: impaired

Insight
She has 1st grade of insight. She is completely denying her illness.
DIAGNOSTIC FORMULATION
The index patient was brought with the chief complaints of rapid loud talk, lack of sleep and
appetite, angry towards others, and do more prayer activities. Which are affect her daily
functioning. Her MSE shows that she has bipolar 1 disorder, current episode manic with
psychotic symptoms . She has visual hallucination. She completely denying her illness hence
has 1st grade of insight.

PROVISIONAL DIAGNOSIS

6A60.1: bipolar 1 disorder

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TREATMENT PLAN
Medication

CASE STUDY C

IDENTIFICATION DATE

Name :C
Age : 40
Gender : Male
Education : Degree
Occupation : Security
Religion : Christian
Marital status : Single
Socioeconomic status : Middle class Region
: Urban

PATIENT’S REPORT
According to the patient, somebody is planning to kill him. He is very sure that others wanted
him to be attacked that he hears such threatening voices more often. This always distracted him
from concentrating in his jobs which gradually made me uninterested in his works.

CHIEF COMPLAINTS

25
1. Others try to harm me

2. Hearing threatening voices

3. Somebody try to kill me

4. Not interested in doing any work

DURATION : 20 Years

ONSET : Insidious

COURSE : Continuous

HISTORY OF PRESENT ILLNES :

The patient was asymptomatic 20 years ago. Then there was a gradual change in his behavior.
He was worried about and sensitive to small issues. He started to observe everything in negative
way. He always believed that others try to kill him and try to harm to him and his family.
Somebody is trying to collect the signed paper from his father (He says that “COLLECTING
BILO” from father). One of his teacher near to his home is trying to collect his wealth and cash
and the teacher want to marry his daughter, He had a history of paranoid schizophrenia 4 years
ago. There was a gradual development of hallucinations especially auditory type and
sometimes visually. He hear the voice like somebody is planning to kill the prime minister. He
can hear the voices of their planning. Jackson, an agent is try harm him. Recently he was
irresponsible in his work and is always suspicious on other. Presently he had sleep problems
and increased symptoms of hallucinations and persecutory thoughts.

HISTORY OF PAST ILLNES :

PSYCHIATRIC ILLNES: Paranoid schizophrenia

MEDICAL HISTORY: Nil significant

DRUG USE: Nil significant

FAMILY HISTORY:

26
His father was an alcoholic and an onset of memory lose. There is a history of psychiatric illness
in his mother. He had good relation with his family.

PERSONAL HISTORY

PRENATAL AND PERINATAL HISTORY: Details were unknown

CHILDHOOD HISTORY

EARLY CHILDHOOD: Details were unknown.

MIDDLE CHILDHOOD: Started to go school at the age of 5 years.

SCHOLASTIC HISTORY: He was an average student and he has completed his degree course.

OCCUPATIONAL HISTORY: He started working as a security in GAS. Currently

unemployed.

PREMORBID PERSONALITY

Interpersonal relationship:

He was an introvert person keeping good relationship with family members, but not with others.

PREDOMINANT MOOD: Worried and cautious.

Attitude Self and Others:

He was concerned about himself and his family but not concerned about others.

Hobbies: Watching T.V., playing cricket.

ATTITUDE TO WORK: Not responsible

27
FANTASIES AND DREAMS: He didn’t report any fantasies and dreams.

MENTAL STATUS EXAMINATION

GENERAL DESCRIPTION

APPEARANCE:

Patient was well kempt and tidy, not maintained eye contact, restless and cautious.

ATTITUDE TOWARDS THE EXAMINER: Good attitude throughout the session, but
restless.

APPROPRIATENESS OF MOOD AND EFFECT:

Subjectively: “I’m ok”.

Objectively: worried and irritable

Patient displayed inappropriate and constricted affect

The patient mood was incongruent.

THOUGHT

STREAM AND FORM OF THOUGHT: Circumstantialities and flight of ideas.

POSSESSIONS: Thought blocking.

THOUGHT CONTENT: He was experienced increased suspiciousness and persecutory

thought.

PERCEPTION: Auditory hallucinations, especially 3 rd person hallucinations.

SENSORIUM AND COGNITION

CONSCIOUSNESS: He was not conscious about the environment.

ORIENTATION: He was oriented to time, place and person.

MEMORY

IMMEDIATE MEMORY:

28
 Immediate digit span forward: 2

Immediate digit span backward: 2

RECENT MEMORY: Intact

REMOTE MEMORY: Intact

ATTENTION: Impaired

CONCENTRATION: Impaired

ABSTRACT THOUGHT:

On proverb testing, asked about “all that glitters are not gold”, he said that sometimes it will
not glitter. And about “Jasmine at our courtyard has no perfume”, he said that use good spray
for the smell.

On similarity testing, asked about mango-banana, he said that these are fruits, and in difference
testing he tell that difference only in shape. So he had concrete thinking.

GENERAL INFORMATION:

He has average level of intelligence. Correctly recalled names of 5 countries and name of prime
minister.

JUDGEMENT:

Social and personal judgement was intact by assess their personal hygiene and their attitude.

Test judgement was assessed by asking, what you would do if a stamped, sealed envelope is
found in a street. He was correctly answered. So test judgement was intact.

INSIGHT:

He has grade 3rd level of insight.

He is aware about his illness, but it is because of others.

DIAGNOSTIC FORMULATION

The index patient was bought with the chief complaints of hearing threatening voices, strong
belief that others try to harm her and someone is trying to kill him which made him loss of

29
interest in his works. His MSE shows that he has the delusion of persecution and delusion of
reference. He has auditory hallucination. He believes that his disorder is because of others and
hence has 3rd level of insight.

PRIVISIONAL DIAGNOSIS: F 22: Delusional Disorder

TREATMENT PLAN:

• Cognitive Behavioral Therapy

• Medications
• Psychotherapy

CASE STUDY D

SOCIO DEMOGRAPHIC DATA

Name :D

Age : 7 Years

Sex :M

Marital Status : Single

Religion : Islam

Education : Studying in 1st std.

Socio Economic Status: Middle

Family : Joint family

PATIENT REPORT

Informant: mother

30
Information: Reliable and adequate

CHIEF COMPLAINTS

• Irritable behavior
• Always engaged in activity
• Doing harmful things to others
• Shifting tasks frequently without completing
• Low marks in exams
• Do not eat food properly
• Not getting sleep at night

ONSET: Insidious

DURATION: 6 Years

COURSE: Continuous

PRECIPITATING FACTOR: Nil

HISTORY OF PATIENT ILLNESS

This child’s birth was as a premature twin, so he had developmental delays in childhood. From
his two years onwards his mother started to notice that his behavior became very irritable in
nature. Not only at his own home but outside also same nature, by speaking unwanted things
and doing something. Then his level of activity is increased. He wants to do anything in full
time. His hands and legs were restless. He will not hesitate to interact with other people even
in new circumstances.

If he feels agitation and anger, he will make quarrel with his twin brother and his younger
brother and sister. When he becomes angry, he will be violent towards his brother and tries to
harm them, also destroyed the house hold article, doing mischiefs and he became a problematic
child to his mother.

His schooling was started at the age of 5 years. At school he showed problems and was not
attentive while at the time of classes and try to irritate other children in the class room. He will

31
always to talk with other children in the class room and wandering in the school campus. His
academic performance was very poor.

For last several months, he had no concentration in the class room, whole time he wants to play;
he became a problematic child to the teacher. He does not want food that time also he used to
play. At night he can’t sleep well.

PAST PSYCHIATRIC OR MEDICAL HISTORY

PAST PSYCHIATRIC ILLNESS: No history of past psychiatric illness

PAST PHYSICAL ILLNESS: He had poor immune systems because of premature boy; he
was admitted at hospital several times for fever.

NEGATIVE HISTORY

No history suggestive of head injury, brain damage, mental retardation, and epilepsy.

TREATMENT HISTORY

No treatment was taken before for this problem.

FAMILY HISTORY

The patient having father, mother, two brothers and one sister. The father aged 38, he is working
in abroad and mother is 30, she is house wife. He has a twin brother and younger brother and
sister.

32
 38 30

2 7 2 2

PERSONAL HISTORY

• Perinatal history: He had premature birth, and then he was under incubator for longer
period of time. He had no proper nutrition for 6 months. He had developmental delays
in motor development and speech.
• Childhood history: He showed hyperactivity.
• Play history: Problems with peers of same age groups
• Educational history: His schooling was started at the age 5. He had poor academic
performance, and he was no interested to take part in extracurricular activities.

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE:

Patient was well-kempt and tidy. His dressing was appropriate and adequate. He is physically
slim.

Overt behavior and psychomotor activity

33
His motor behavior is include gestures and appropriate facial expression and is restless during
the session.

Attitude towards the examiner

Cooperative towards examiner.

SPEECH CHARACTERISTICS

His speech was clear, goal directed and coherent. The volume and tone of speech was normal.

MOOD AND AFFECT

Subjectively: I’m happy

Objectively: Ethymic

Appropriateness of mood and affect: He shows appropriate affect to his thought.

THOUGHT DISTURBANCES:

• Stream of thought: no abnormality detected

• Content of thought: no abnormality detected
• Possession of thought: no abnormality detected
• Form of thought: no abnormality detected

PERCEPTUAL DISTURBANCES:

No perceptual disturbances in any modality were detected.

SENSORIUM AND COGNITION

• Consciousness: He was alert and aware of the environment.

• Orientation: He was oriented to time, place and person.
• Memory:

Immediate retention and recall

Immediate digit span forward: 4

Immediate digit span backward: 4

Recent memory: intact

Remote memory: intact

34
 • Concentration: The patient was unable to concentrate as he couldn’t do the serial
subtraction of 3 from 50.
• Attention: Poor ability to attend the conversation.
• Abstract thinking: Functional.

On abstract thinking tested to difference between apple and orange. He tells that the orange
color is orange and the apple is red. And the both are fruits.

JUDGMENT

Social and personal judgment was adequate

Test judgment was good

INSIGHT

He has 1st level of insight

He is not aware about his illness.

DIAGNOSTIC FORMULATION

The patient was brought with chief complains of irritable behavior and always engaged in
activity, doing harmful things to others, shifting tasks frequently without completing and got
low marks in exams. He is not taking food properly and not getting sleep at night. His MSE
shows that patient has attention and concentration problems.

PROVISIONAL DIAGNOSIS

F90.0 Attention-Deficit Hyperactivity Disorder (ADHD)

TREATMENT PLAN

Psycho-education was given to the parents about the patient’s illness. Medicines were
prescribed to improve attention and control restlessness. Attention Enhancement Techniques
like Grains sorting, letter cancellation and water coloring to improve the ability to concentrate
were demonstrated.

35
 CASE STUDY E

SOCIO DEMOGRPHIC DATA

Name :E

Age : 32

Sex : Male

Marital Status : Married

Religion : Hindu

36
Education : Engineering graduate

Occupation : IT Firm

Socio Economic Status: Middle Class

Region : Urban

PATIENTS REPORT

Informant: wife

Information: adequate and consistent

Reliability: Good

CHIEF COMPLAINS

• Constant warry through the day -1 year

• Difficulty in concentration started 6 month ago
• Nervousness , muscle tension, sweating and sleeplessness started 6 month ago

HISTORY OF PRESENT ILLNESS

• 1 year ago he was apparently normal, then developed worry about his daily work and
felt apprehensive while carrying it out, worry was constant and was present all through
the day.

• His worries increased gradually and he could not concentrates on work and would do
same minor mistake which resulted in nervousness, trembling muscle tension,
sweating and racing heart beats accompanied with difficulty in initiating sleep.
• There was no significant past or family history.

FAMILY HISTORY

37
The patient is married. His wife is house wife. And he has two sons.

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE, ATTITUDE & BEHAVIOUR:

Patient was conscious, oriented, alert, ambulant, kempt, cooperative rapport established, took
the seat offered, was interested in the interview, eye contact made and maintained.

PSYCHOMOTOR ACTIVITY: It is normal.

SPEECH CHARECTRISTICS:

His speech was spontaneous, relevant and coherent. The tone of speech was increased and rate
was normal. His reaction time was normal and also no stuttering or cluttering.

MOOD AND AFFECT

Subjectively: I’m afraid and worried

Objectively: anxious, reactive, normal range of emotions

THOUGHT

• Form of thought: No derailment /neologism

• Stream of thought: No circumstantiality/ flight of ideas/ poverty of speech
• Content of thought: warry and apprehension about future
• Possession of thought: No obsession / compulsion / thought alienation.

38
PERCEPTUAL DISTURBANCES

No perceptual disturbances in any modality were detected

SENSORIUM AND COGNITION

• Attention: arousable
• Concentration: intact
• Orientation: intact
• Memory:
Immediate memory: intact
Recent memory: intact
Remote memory: intact
• Intelligence: intact

JUDGEMENT

Social, test and personal judgement was intact

INSIGHT

He has 3rd level of insight. He is aware about his illness, but it is because of external causes.

DIAGNOSTIC FORMULATION

The patient was brought with chief complains of constant worry, difficulty in concentration,
nervousness, muscle tension, sweating .He is not getting sleep at night. His MSE shows that he
is very anxious and fear.

PRIVISIONAL DIAGNOSIS: F 41.1: Generalized Anxiety Disorder

TREATMENT PLAN:

• Psychotherapy

39
 • Medication

CASE STUDY F
SOCIO DEMOGRAPHIC DATA

Name :F

Age : 13 years

Sex : Male

Education : 7th standard

Occupation : Nil

Marital status : Nil

Religion : Muslim

40
Socio economic status : Middle class family

Informant : Father

Information : Reliable and adequate

CHIEF COMPLAINTS

• Poor in studies
• Unable to concentrate
• Poor comprehension
• Difficulty in reading
• Difficulty seeing similarity and difference in letters and words
• Avoiding activities that involve reading

ONSET : Insidious

Duration : 3 years

Course : Continuous

Precipitation factors : Reading difficulty and unable identify letters.

HISTORY OF PRESENT ILLNESS

The patient was apparently functioning well before 3 years. According to the patients parents
that they states after 3 years he started to speak out the words. He shows less interest towards
studies. He always avoids the activities that involve reading. If parents forces him to study he
shows anger to them highly.

Parents says that teacher always report that he is unable to read fluently. He always avoids the
activity like reading. He never listen or hear to them. Because of all these increased issues the
teacher were suggested to bought him at this clinic.

NEGATIVE HISTORY:

No suggestive history of organic disorder

No suggestive history of criminal records

No suggestive history of epilepsy

41
No suggestive history of substance abuse

No suggestive history of mood disorder

TREATMENT HISTORY

Medical history: no specific medical conditions has been meted in past history

Psychiatric history: no specific psychiatric disorders has been diagnosed.

PERSONAL HISTORY

PRENATAL PROBLEMS

There is no prenatal developmental issues in his birth.

DEVELOPMENTAL DELAYS

He shown the developmental delay on late talking etc.

CONDUCT DISORDER & ATTENTION DEFICITS IN CHILDHOOD

Patient was show doing works in his childhood

SEPARATION DIFFICULTIES/ SOCIAL ANXIETY IN CHILDHOOD: No

EDUCATIONAL HISTORY

The person is below average student and he is studying in 7th standard.

FAMILY PROBLEM HISTORY: Nil

OCCUPATIONAL HISTORY: Nil

SEXUAL HISTORY: Nil

MARITAL HISTORY: Nil

SOCIAL SUPPORT: Family, community, friends

FAMILY HISTORY:

His father 35 years old, studied up to tenth standard. He is working driver. He is dominant and
responsible nature. His mother 30 years old currently, studied up to 7 th standard, she is house

42
wife. He is eldest in his family. He has one younger brother. They are economically good and
their living condition is good and there is no other mental illness reported in the family line.

35yrs 30
yrs

13yrs 3yrs

PREMORBID PERSONALITY

MOOD – Happy and mingling

INTERPERSONAL RELATONS – Good interpersonal relationship

ATTITUDE TO WORK & RESPONSIBILITY – Irresponsible

COPING STYLE – Aggressive

HOBBIES – Games, adventures seeking

MENTAL STATUS EXAMINATION

GENERAL APPEARANCES

Adequate dressing with less physical and personal hygiene. He was established eye contact and
not maintained. His psychomotor activity was restless. He is very in attentive and conscious.

ATTENTION AND CONCENTRATION

In attention and less concentration was showed while backward counting and serial subtraction.

MEMORY

His immediate, recent and remote memories were intact.

43
INTELLIGENCE, MATHEMETICAL ABILITIES & COMPREHENSIVE

General intelligence, calculation abilities and comprehensive were found to below average
level.

ABSTRACT THINKING: Concrete level

ORIENTATION: He was oriented to time, place, date and person.

VOICE AND SPEECH: His speech was coherent, goal directed and audiable. The reaction
time is normal and fluctuation is normal.

PERCEPTION: His perception level is normal.

THOUGHT:

• Stream of thought: Normal

• Content of thought: Normal
• Possession of thought: Normal
• Form of thought: Normal

JUDGEMENT: Personal, social and test judgement was poor.

INSIGHT:

Level-1 – Complete denial of illness.

DIAGNOSTIC FORMULATION

The intex patient F 13 yrs old male was chief complaints of poor in studies, unable to
concentrate, poor in reading, avoids the activities like reading. The MSE findings shows that
he is cooperative and friendly with examiner. He established and mentioned the rapport eye to
eye contact. His attention and concentration is aroused and not sustained. His recent and
immediate and remote memory is in intact. His intelligence is average level. His voice and
speech is normal. No perceptual disturbances is present. No thought disturbances was seen. His
subjective mood is aggressive and his objective mood is appropriate. His affect is restricted.
His insight level is level 1.

PROVISIONAL DIAGNOSIS

Based on the case report and MSE findings the patient has
LEARNING DISABILITY=DYSLEXIA.

44
TREATMENT PLAN

First line treatment is pharmacotherapy. Patient and family are given psycho education in which
they are explained about the cause and importance of compliance to medication and patient
was insisted that should be given by the family and regular check up with the doctor.

CASE STUDY G

SOCIO DEMOGRAPHIC DATA

Name :G

Age : 50

Gender : male

Occupation : bank manager

Socio economic status : upper class

INFORMANT:

Name of informant: sister from church and self

45
Duration of relationship with client: 6 months

INFORMATION:

Reliability: reliable & Validity: valid

CHIEF COMPLAINTS AND DURATION:

• 3-time bathing
• Over hygienic
• Very concerns on time, exercises.
• Repeated checking of door when go out,
• Suspicious, suspicious about wife, he had thrusted his wife and wife got injury due to
his attack.
• She got the coma state and died after days during treatment in hospital.
• Killed his school mate.
• Hearing voices, false thoughts about another person, seeing unusual images, seeing
wife and

• Speaks with died wife.

BRIEF HISTORY OF PRESENT ILLNESS

Mode of onset: abrupt

Course: continuous
Duration: 2 years

HISTORY OF PRESENT ILLNESS

Sleep: decreased
Appetite: decreased
Predisposing factors: parent’s negligence and attitude towards loved ones.
Precipitating factors: death
Perceptual factors: lack of love, relations.
PAST MEDICAL HISTORY: nil
PAST PSYCHIATRIC HISTORY:
Previous consultation and treatment

46
PTSD FAMILY HISTORY
Consanguinity in parents: NIL
Family history of
• Mental illness: NIL
• Major medical illness: NIL
• Substance usage: NIL
• Suicide: YES
• Mental retardation: NIL
• Epilepsy: NIL

PERSONAL HISTORY
Physical illness during childhood: nil
Parents and home situation: not appropriate, uninvolved parenting style
MARITAL HISTORY
Type of marriage: Arranged

Marital satisfaction: poor sexual satisfaction: Appropriate

Marital adjustment: low sexual adjustment: Appropriate
Number of children, their age, education, and health status: NIL
Relationship with parents: not appropriate
Relationship with siblings: not appropriate
Relationship with peers: not appropriate
Personality features and health status: well, talkative, social, active.
Physical illness during childhood: nil
PARENTS AND HOME SITUATION
Siblings age: nil
Family beliefs race religion, issues etc.: very poor relationship with parent
EDUCATIONAL HISTORY
Academic performance: good
Extracurricular activities: yoga, music, chess
Relationship with teachers: poor
Peer relationship: low

47
Any disciplinary problem: nil
History of substance abuse: Nil
PREMORBID PERSONALITY
Inter personal relationship: (Introverted/extroverted; interpersonal relationships with families,
friends, and work colleagues; ease of making and maintain social relationship) =introverted,
very poor and unapproachable with family, friends and colleges, difficult to make and maintain
relationship

Use of leisure time: (hobbies, interests, intellectual activities, critical faculty;

energetic/sedentary) = chess, melody music, yoga, facial exercises

Predominant mood: optimistic/pessimistic; stable/ prone to anxiety; cheerful/despondent;

reaction to stressful life events. = pessimistic, prone to anxiety; despondent

Attitude to work and responsibility: decision making; acceptance of responsibility; flexibility;

perseverance; foresight:

Moral standard: religious belief; tolerance of others standards and beliefs; conscience; altruism
Fantasy life: sexual and non-sexual fantasies; day dreaming – frequency and content; recurrent
or favourite day dreams; dreams.

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE AND BEHAVIOR
Personal hygiene: well kempt (very hygienic symbols the OCD)
Hair: well-groomed
Finger nails: cleaned
Dressing: appropriate
Eye to eye contact: well, maintained
Mood: socially withdrawal (what they feel & emotion e.g.; socially withdrawal, mood content:
anhedonia /sad/sorrow. )

Affect: appropriate/ non (what they are showing & experience e.g.: how do u feel now)

Rapport: hostile

Psychomotor activity: agitated

48
SPEECH
Intensity: abnormally soft
Reaction time: sudden
Speed: average
Volume: average
Ease of speech: hesitant
THOUGHT
(Comparatively less in children, it depends upon disease)
• Stream of thought: retardation of thinking, perseverance
• Content of thought: delusions, hallucinations, homicidal ideas,
• Possession of thought: obsession, compulsion
• Form of thought: desultory thinking

COGNITIVE FUNCTIONS:
Consciousness: (simply call their name) intact

Orientations:

Time: (what’s time now, date, night or day); impaired

Place: where is now, where were you in the morning; not oriented/ impaired
Person: who is this with you impaired
Attention and concentration: Impaired
MEMORY
Immediate memory: intact
Recent memory: intact
Remote memory: intact
DIAGNOSTIC FORMULATION
The client G was 50 old male. He hails from upper-class family and he was the only one for his
mother and father. Mother was a doctor and father was a lawyer. Itself that due to their busy
work the client childhood was lonely and he faced uninvolved parenting style. The client had
PTSD. Due to his father’s liability on work, he witnessed death of their servant’s family. Then
he had faced extreme obsessions like, repeated cleaning, checking, very hygienic, suspicious.
He had a quarrel with his wife due to his suspiciousness and wife got injured to coma state. He

49
also faced delusions, visual and auditory hallucinations after the death of wife and killed a
classmate. He had loved to live lonely. Not interested to make social , family , peer relationship.
His memory, thoughts were impaired.

PROVISIONAL DIAGNOSIS

OCD
TREATMENT PLAN

• CBT
• Medication

CASE STUDY H

SOCIO DEMOGRAPHIC DATA

Name :H
Age : 12years
Sex : Male
Education : 6th standard
Occupation : Nil
Marital status : Nil
Religion : Muslim

50
Socio economic status : Middle class family
Informant : Mother
Information : Reliable and adequate

CHIEF COMPLAINTS
• Poor in studies
• Unable to concentrate
• Very much irritable and increased adamancy
• Inattention towards everything
• Increased temper tantrums and hyper

Onset: insidious

Duration: 3 years

Course: continuous

Precipitation factor: inattention and hyperactive

HISTORY OF PRESENT ILLNESS

The patient was apparently functioning well before 3 years. According to the patients parents,
the adamant and inattentive towards them. He shows less interest toward studies. He always
like to lay and never sit idle for little time. If parents forces him to study he shows temper
tantrums in which they let him free to play.

Parents says that teacher always report that he is unable to sit in the class. He always roams in
class time. He never listen or hear to them. Other children complaints that he use to make flight
with them. Because of all these increased issues and unable at home he was bought at this
clinic.

NEGATIVE HISTORY

No suggestive history of organic disorder

No suggestive history of criminal records

No suggestive history of epilepsy

No suggestive history of substance abuse

51
No suggestive history of mood disorder

TREATMENT HISTORY

Medical history: no specific medical conditions has been meted in past history.

Psychiatric history: no specific psychiatric disorders has been diagnosed.

PERSONAL HISTORY

Prenatal problems: There is no prenatal development issues in his birth.

Developmental delays: There is no kind of developmental delays shown in his childhood days.

Conduct disorder & Attention deficit in childhood: Patient was very impulsive and inattentive
in childhood.

Separation difficulties/Social anxiety in childhood: No

EDUCATIONAL HISTORY

The person is average student and he is studying in 6th standard.

FAMILY PROBLEMS WHILE GROWING UP: Nil

OCCUPATIONAL HISTORY: Nil

SEXUAL HISTORY: Nil

MERITAL HISTORY: Nil

SOCIAL SUPPORT: Family, community, friends.

FAMILY HISTORY

His father 35 years old, studied up to tenth standard. He is working abroad. He is dominant and
responsible nature. His mother 30 years old currently, studied up to 7 th standard, she is house
wife. He is eldest in his family. He has one younger sister. They are economically good and
their living condition is good and there is no other mental illness reported in the family line.

52
 30yrs
35yrs

12yrs 7yr
s

PREMORBID PERSONALITY
Mood- Happy and mingling
Interpersonal relations- Good interpersonal relationship
Attitude to work & responsibility- Irresponsible
Coping style- Aggressive
Hobbies- Games, adventures seeking

MENTAL STATUS EXAMINATION

GENERAL APPEARANCES
Adequate dressing with less physical and personal hygiene. He was established eye contact and
not maintained. His psychomotor activity was restless. He is very inattentive and conscious.

ATTENTIVE AND CONCENTRATION

Inattention and less concentration was showed while backward counting and serial subtraction.

MEMORY

His immediate, recent and remote memories were intact.

INTELLIGENCE, MATHEMATICAL ABILITIES & COMPREHENSIVE

General intelligence, calculation abilities and comprehensive were found to be average level.

ABSTRACT THINKING: Concrete level

ORIENTATION: He was orientated to time, place and person.

53
VOICE AND SPEECH

His speech was coherent, goal directed and audiable. The reaction time is normal and
fluctuation is normal.

PERCEPTION: His perception level is normal.

THOUGHT
• Stream of thought: Normal
• Content of thought: Normal
• Possession of thought: Normal
• Form of thought: Normal

JUDGEMENT

Personal, social and test judgement was poor.

INSIGHT

Level 1- complete denial of illness.

DIAGNOSTIC FORMULATION

The intex patient H 12yrs old male was chief complaints of poor in studies, unable to
concentrate, very much irritable and increased adamancy, inattention towards everything,
increased temper tantrums and hyper active. The MSE findings shows that he is cooperative
and friendly with examiner. He established and maintained the rapport and eye to eye contact.
His attention and concentration is aroused and not sustained. His recent and immediate and
remote memory is in intact. His intelligence is average level. His voice and speech is normal.
No perceptual disturbance is present. No thought disturbances was seen. His subjective mood
is aggressive and his objective mood is appropriate. His affect is restricted. His insight level is
level 1.

PROVISIONAL DIAGNOSIS

Based on the case report and MSE findings the patient has ATTENTION DEFICITS
HYPERACTIVE DISORDER (ICD 10F 90.0).

TREATMENT PLAN

54
First line treatment is pharmacotherapy. Patient and family are given psycho education in
which they are explained about the cause and importance of compliance to medication and
patient was insisted that should be given by the family and regular check up with the doctor.

CASE STUDY I
SOCIO DEMOGRATIC DATA

Name :I

Age : 54yrs

55
Sex : Male

Marital status : married

Religion : Muslim

Education : 6th standard

Occupation : Cooli worker

Address : Vengode

PRESENTING COMPLAINTS

According to the patient, he feels suspicious towards wife, hearing voices and some one is
talking to him, and also sleep decreased.

INFORMANTS

Informants: Wife

Reliability: reliable

Adequacy of information: adequate

CHIEF COMPLAINTS

• Irresponsible behaviour
• Food intake decreased
• Sleep decreased
• Suspicious towards wife
• Collecting bottles and fitting different liquid (water, tea, starch etc.)
• Self- talking, clapping, crying, laughing are increased

Mode of onset: Gradual

Course: Continuous

Duration: 15yrs

Precipitation factor: Nil

56
HISTORY OF PRESENTING ILLNESS

Patient was apparently well before 15 yrs, then he was going to abroad, from there he was
started with suspicious towards wife, and also decreased sleep are reported by the wife. The
wife reported that after he comes from abroad he was not go for any job for 5 yrs. He always
sitting in his locked room only come out of the room to drink tea and go and lie on the room,
also he was founded to be the irresponsible behaviour, at that time they was take him for
hospital to consult the psychiatrist and hospitalized since for 4 yrs and after that he medicated
for 3 month, while he discontinue medication by himself and again started the irresponsible
behaviour, decreased food intake, sleep decreased, self-talking increased, crying and laughing
without any reason. Clapping are reported wife and again take treatment from puthanpalli
doctor but he didn’t ready to take medication and also showing the violent behaviour and
increases the verbally and physically abuse the wife and children continuously. He was brought
the cockroach poison kept under his bed, and also take the chopping knife to his bed room and
kept under the bed while the time of sleeping was reportedly the wife, after that the wife is
reported that the patient was make fake visiting cards about him that he was doing the nature
and Islamic treatment for the people who suffered from disease and it was distributed among
the neighbour and other and also increased the religious activities at that time after that he is
not taking food , not drinking and always saying that some insurance people are spray some
poison to his food items and expressing to wife the aggressive behaviour, after for a few months
he stayed with his brothers and sisters and he did not taking medicine properly and from there
the patient was going outside and wandering for hours and self-talking, laughing band
collecting bottles and also filled the bottles with different liquids and where taken away for
testing purposes continuously. Following these complaints he was brought to CHL hospital for
managing his current conditions.

NEGATIVE HISTORY

There is no history suggestive of fever, seizures, head injury, disturbance in memory and loss
of consciousness.

PAST HISTORY: No, reliable information.

TREATMENT HISTORY

He was consulted a psychiatrist in Thrissur, where he was hospitalized for 4 yrs and he is not
continued medicines properly and he stopped medication his own, later the patient was taken

57
to Puthanpalli doctor to consult him again for the specific reasons but he medicated for few
weeks and stopped medication by him-self.

PERSONAL HISTORY

• Birth- not reliable information

• Milestone- no reliable information
• Childhood- no reliable information
• Play- no reliable information
• Educational history- no reliable information
• Occupational history- he was worked at abroad before 24 yrs and after that he go for
some coolie worked for few months in vegode.
• Marital history- got married when he was 29 yrs old, he has 4 children. When at the
time he was worked at abroad, no issues reported for first 2 yrs. After that wife reported
he is being increasingly suspicious about her. After he went from abroad and get
married 2nd wife and in her he has 2 children. But in between them there was some
conflict has reported by 1st wife, that there were get divorced.
• Sexual history- he is heterosexual orientation.

• Premorbid personality- the patient was extrovert, he was very cooperative and also take
care of his family and also he was bright, cheerful and very optimistic.

FAMILY HISTORY

He was born from house, his father was died and mother is house wife, they are eight children
and the patient was second born child and he was studied up to 6 th std. There is no family
history of organic psychiatric condition, psychiatric illness, substance abuse, suicides in family.

58
 32yrs

54yrs

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE:
The patient was well kempt dressed appropriately and his attitudes towards examiners was
cooperative during the test.

He was feeling drowsy in between the session and he reported it as the effect of medication.

Rapport was established easily. His eye contact was initiated and maintained and attention was
aroused and sustained.

Psychomotor activity was normal.

ATTENTION AND CONCENTRATION:

Attention and concentration of patient is found to be intact.

MEMORY:

The patient immediate, recent and remote memory were intact.

GENERAL KNOWLEDGE AND COMPREHENSION:

The patient G, K, and comprehension was found to be adequate as and he responded

appropriately to the questions.

ARITHEMATIC ABILITIES: Arithematic ability of patient was to be adequate as .He could

answer for 3 questions correctly.

59
ABSTRACT THINKING: His answer is not appropriate in proverb test. The similarities and
differences are appropriate answer he gave. Hence his abstract ability is inadequate.

ORIENTATION: He was oriented to time and place.

SPEECH: He spoke spontaneously and the amount of speech was normal. The tone, tempo and
reaction time of speech was normal. Prosody was maintained and speech was relevant and
coherent.

PERCEPTUAL DISTURBANCE: Hallucination is present the auditory hallucination with

third person is present.

JUDGEMENT: The social and test judgement of a patient is intact as he responded

appropriately for the questions whereas the personal judgement founded to be in adequate.

MOOD AND AFFECT: Subjectively he reported to be sad. Objectively appeared to be sad.

Range of his mood was with in normal limits, reactivity was appropriate and congruent.

THOUGHT DISTUBANCES:

• Stream of thought: flight of ideas and circumstantiality is present.

• Form of thought: formal thought disorder is present.
• Possession of thought: absence of obsessions, compulsion thought insertion and
thought withdrawal.
• Content of thought: delusion is present, where the delusion of persecution and also
delusion of grandiosity.

INSIGHT

Insight level 1: complete denial of illness

DIAGNOSTIC FORMULATION

54 years old married educated up to 6th std from middle socio-economic status, hailing from
semi urban area, presented with complaints of irresponsible behaviour, decreased food intake,
decreased sleep, suspicious towards wife and collecting the bottles, and filled with different
liquids and increased self- talking clapping crying and laughing without any reason since for
past 15 years. No history suggestive of fever seizures head injury disturbance in memory and
loss of consciousness. He was medicated for 4 yrs from Thrissur hospital and few month

60
medicated from Puthanpalli doctor , but he do not continued the medication properly. His
premorbid personality is found to be normal.

On MSE, he was well kempt and cooperative his psychomotor activity was normal. Speech
was relevant and coherent, his mood was subjectively sad and objectively appeared to be sad.
On the thought of the “I” was founded that have disturbance in form, stream and content, and
there is no disturbance in possession. He was oriented, memory was intact, attention was
aroused and sustained, adequate, general information and arithematic and hence adequate in
intellectual capacity. Thinking is not tend to be more concrete and thus the abstract ability is
inadequate. The test and social judgement is adequate whereas impaired in personal judgement
could be elicited and his insight was found to be grade 1, complete denial of illness.

PROVISIONAL DIAGNOSIS

On the basis of history and MSE first preferable diagnosis according to ICD- 10 is F.20.0

PARANOID SCHIZOPHRENIA.

TREATMENT PLAN

• Pharmacotherapy
• Psychotherapy

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 CASE HISTORY J

SOCIODEMOGRAPHIC DATA

Name :J

Age : 14

Sex : Male

Religion : Hindu

Educational status : Studying at 9th standard

Socioeconomic Status : Middle class

Language Mode : Malayalam.

INFORMANT

Relationship: Mother

Primary caregiver: Yes

Informant: Reliable and Adequate

CHIEF COMPLAINTS

• Difficulty in reading.

• Difficulty in writing.

• He feels difficulty to differentiate M and W, B and D, and R and Y

• Shows difficulty in arithmetical area.

• Difficulty in memorizing learned materials.

• Poor reading fluency.

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 • Difficulty in pronouncing words.

• Difficulty in listening and responding to series of direction.

• Poor comprehension.

Duration: Since childhood onwards

Course: Continuous

Onset: Gradual

Precipitating factor: Nil

HISTORY OF PRESENT ILLNESS

The patient is a 14 year old boy who living with his father and mother. He was studying in
9thstandard in Assumption High School. He was facing difficulties in learning the material
from the early age itself. The problem in learning was first reported by his teacher, when he
was in 3rd standard. He has the difficulties to read a material in fluent way. He has difficulties
to pronounce words. He was difficulty to differentiate words like M and W, B and D, and R
and Y. He has poor handwriting and also has difficulty in writing. He was facing difficulties to
solve mathematical problems. He was reading a sentence by reading each letter by letter. He
was unable to memorize the learned materials. He forgets the materials that he just learned
before. He was unable to understand the meanings of the material that he was reading. He was
very slow in reading. He has some difficulties to listen what others saying to him and follow
the instructions. He told that he was not interested in studies. He skips the exams in school. He
had difficulties to follow the lectures in the class.

ASSOCIATED DISTURBANCES

Sleep: Normal Appetite:

Normal.

Weight: Normal.

Social functioning: Normal.

Occupational functioning: Normal.

PAST HISTORY OF MEDICAL ILLNESS AND PSYCHIATRIC ILLNESS

Similar episodes: Yes

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Severity: Continuous, Ongoing.

Negative history: There is no significant negative history.

TREATMENT HISTORY

The patient has taken treatment from Nimhans Kozhikode as instructed by the school
authorities. When he was in 7th standard he has taken treatment from Govt. Hospital, manjeri.
At present he is taking treatment under consultant psychologist kochuthressia

FAMILY HISTORY

Religious traditions: He was born in a Hindu family.

Family members: The patient was only child. The marriage of the parents was
nonconsanguineous.

Type of family: Nuclear

Psychiatric illness in family: No.

Source of family income: Father was in abroad.

PERSONAL HISTORY

Prenatal history: C Section delivery, wanted child, full term, underweight.

Feeding habits: Breast feed, not reported any eating troubles or allergies.

Major illness during infancy: Not reported any illness

Developmental milestones: His social, motor and cognitive development was delayed. The
speech development was poor.

Major physical illness during childhood: Not reported any major illness.

Emotional and behavioural disturbances during childhood: not reported any illness.

Home atmosphere during childhood: Good

Parental lack: No.

EDUCATIONAL HISTORY

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Break in studies: No.

Frequent change of school: No.

Type of school: Rural.

Medium: Malayalam.

Academic performance: Below Average student

Relationship with teachers: Good.

Relationship with students: Good.

PREMORBID PERSONALITY

Attitude to self: Could not be elicited.

Moral & religious attitude: Could not be elicited.

Social relationship: Normal.

Mood: Appropriate.

Leisure time spent: Playing.

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE AND BEHAVIOUR

General appearance: Appropriate.

Eye contact: Established and not maintained.

Attitude towards examiner: Cooperative.

Comprehension: Intact.

Gait and posture: Normal.

Motor activity: Normal.

Social manner and non-verbal behavior: Appropriate.

Rapport: Established.

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SPEECH

Rate and quantity of speech: Normal.

Volume and tone of speech: Normal Pitch.

Flow and rhythm of speech: Smooth.

Relevance: Relevant.

Coherent: Coherent.

MOOD AND AFFECT

Mood: Appropriate.

Affect: Euthymic.

THOUGHT

Stream and Form of thought: Normal.

Content of thought: laziness, lack of attention.

PERCEPTION

Hallucination: No presence of hallucination.

Illusion: No presence of illusion.

COGNITION

Level of consciousness: Conscious.

ORIENTATION

Time: Intact.

Place: Intact.

Person: Intact.

ATTENTION AND CONCENTRATION

Digit span test: Digit forward : 4

Digit Backward: 2

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Serial subtraction: Impaired

Days of month: both forward and backward is impaired.

The attention and concentration is aroused and not sustained.

MEMORY

Immediate: Intact Recent:

Intact.

Remote: Intact.

INTELLIGENCE

General information: Average Comprehension:

Average.

Arithmetic: Below Average.

Vocabulary: Average.

ABSTRACT THINKING: Appropriate

JUDGEMENT

Self-judgement: Good.

Social judgement: Good.

Test judgement: Good.

INSIGHT: Denial of illness (Grade I)

DIAGNOSTIC FORMULATIONS

J was brought to the hospital with the chief complaints of difficulty in reading, difficulty in
writing, he feels difficulty to differentiate m and W, B and d, and R and Y, shows difficulty in
arithmetical area, difficulty in memorizing learned materials, poor reading fluency, difficulty
in pronouncing words, difficulty in listening and responding to series of direction and poor
comprehension. On MSE, the dressing of patient was appropriate. The patient was cooperative
and established the rapport and eye contact. He has normal motor activity. The rate and quantity

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of speech was normal. The volume and tone of speech was normal and flow and rhythm was
smooth. The mood and affect was appropriate and euthymic. The stream and form of thought
is normal. The content of thought consists of lack of attention and laziness. There is no
hallucination and illusion. The patient is conscious and oriented to time, place or person. The
patient’s attention and concentration was is arouse and not sustained. The immediate, recent
and remote was intact. The patient has average level of general knowledge, vocabulary and
comprehension. The arithmetic is below average. The abstract thinking is appropriate. The test,
self and social judgment was intact. The patient has grade I of insight.

PROVISIONAL DIAGNOSIS

According to case history and mental status examination of the patient, he was being diagnosed

as MIXED DISORDER OF SCHOLASTIC SKILLS – F 81.3

TREATMENT AND MANAGEMENT PLAN

• Individualized Education Programme

• Psycho education
• Parental counseling

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 CONCLUSION
Completed 30 days of internship (90 hours) at PSYCHE CARE COUNSELLING CENTRE
AND EDUCATIONAL INSTITUTION, KSEB office , 2 nd flour , Mundakkulam ,
Muthuvallur (p.o) , Kondotty – Edavannappara road of Malappuram Dt, which is headed by
Mrs. Reema Ummer, consultant psychologist and child remediator.

PSYCHE CARE deals with different psychological cases, such as child behavioural problems,
adolescent issues, family problems, academic problems, many kind of mental disorders
including mood disorders, somatic complaints, job related issues, anxiety related problems and
also lifestyle related problems.

During the internship period, attended the classed based on counselling and psychotherapy ,
psychological assessments, cognitive behavior therapy, dialectical behavior therapy, ethical
issues and legal considerations, behavior management, mindfulness training, relaxation
training, assessment and interventions in learning disability, sexuality, gender, sexual
dysfunctions, professional skills, etc. Along with the above, we also had case discussion, case
presentation, assignment preparations, seminar presentations, etc. which we really found
extremely useful. Even though we could not directly interact with patients, through
telecounselling sessions, we could actually feel the same amount of passion and empathetic
consideration towards the clients.

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 REFERENCES
Contemporary clinical psychology: second edition, Thomas G. Plante

Diagnosis Made Easier; principles and techniques for Mental Health Clinicians- James
Morrison

Diagnostic and statistical Manual of Mental Disorders (DSM-5) http://www.apa.org/

James N Butcher ; Abnormal Psychology

Psychiatric history taking – Dr. Nithin Sethi

The ICD 10; classification of Mental and Behavioural Disorders www.psychologytoday.com

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