CASE HISTORY REPORT FOR “VN”

I. PSYCHIATRIC REPORT

A. Identification

Name: [REDACTED]

Age: 54 years (as written in files)

DOB: 1966 (as informed by the client)

Sex: Male

Gender:NA

Sexual Orientation: Heterosexual

Religion: Hindu

Sub-Sect: NA

Educational Qualification: Studied up to 6th Standard.

Current Area of Residence: In-Patient at Regional Mental Hospital, Thane.

Family Area of Residence: Bhayander

Personal Phone No.: NA

Case No.: [REDACTED]

Informant: Self
B. Chief Complaint

The patient has been admitted with complaints of excessive talking, aggressiveness,

wandering out, and erratic behavior. The patient currently reports fear of being given a death

sentence, and feelings of loneliness.

C. History of Presenting Problem

The patient has been admitted in the Regional Mental Hospital, Thane, since June 2018 for

excessive talking, aggressiveness, wandering out, and erratic behaviors. They are currently

being given antipsychotics. It seems from their file that they have been frequently been

admitted as an inpatient at the hospital since 2010.

D. Past Psychiatric and Medical History

No records of medical history of the client was found in their files, however the client said

that they underwent a surgical operation for appendicitis, and they showed what looked like a

surgical scar on their abdomen.

Their psychiatric history primarily revolves around their frequent admission to Regional

Mental Hospital, Thane for the past 8 years. No other form of psychiatric history was

mentioned in the client’s case file at the hospital nor was it recalled by the client.

They however did mention being called out for eccentric behavior since childhood.
E. Family History

The client said that they currently live with their sister when they are discharged from the

hospital. Their parents are deceased- their father due to brain hemorrhage (they also said that

they had lung cancer), their mother due to kidney cancer, and their step-mother due to brain

hemorrhage too. The client said that their father, a follower of Christianity, was married to

twice. The client was born to their father’s first wife who was Hindu, and to whom the client

said their father lied to about their identity (their religion) and later got separated when their

lie was discovered. The client has 6 siblings from the first marriage, 4 females and 2 males.

The client has 6 siblings from the second marriage too, 4 females and 2 males.

The client said they lived in DD Chawl in Worli (when looked up on Google, it was

said that the chawls were called “BDD”) when they were young, with their parents. Their

mother worked as a nurse. The client could not recall what their father did for employment.

They also said that both their moms lived together. The client said that they had a good

relationship with their parents. The clients said that they later moved to Lokhandwala.

The client said that that they have a good relationship with all their siblings except

their brother to whom they don’t talk to anymore because he didn’t let the client marry a

women they loved. The client says that when they are discharged, they live with their sister in

Nalasopara but in their case file the informant, a sister of the client whose Aadhaar details

was provided, showed the area of residence of the sister to be in Bhayander. However, the

description the client gave of their area of residence was accurate (the mental health

professional examining the client had lived nearby), thus it is possible that their area of

residence has changed since the making of their Aadhaar card. The client could not recall

anything about residence in Bhayander.

1.​ Early Childhood

The patient did not have information regarding their early childhood, and thus information

could not be obtained.

2.​ Middle Childhood

The client said that they studied till 6th Standard in an English medium school in Dadar.

They said that they failed in English subject, twice. They said that the school complained

about them “overacting” in the class. They said liked playing cricket a lot.

3.​ Adolescence

The client mostly had male friends and had no problems in establishment of their gender

identity as a man. They also seemed to have a healthy interest in masturbation (and

pornography).

4.​ Adulthood

The client does not recall when thee onset of their problems occured. They recalled often

taking their medications at a movie theatre because there was air conditioning there. They

have also said that they had gone to restaurant with a friend and come out after eating a meal

and not paying up. They were also put in jail once. They haven’t had any history of substance

abuse.

​ The client said that they have gone to Kuwait to work in 1986 (they believed their age

was 40 then) and came back when the Gulf War had Kuwait involved. After coming back

they said they worked as a bodybuilding trainer for film stars such as Salman Khan and
Sanjay Dutt. They also believe that they are looking out for them at the hospital.. The client

also thinks that the people from TV are talking to them, and they like to imitate what the TV

does. They said that one time in the past, they imitated what they saw in the TV and broke the

TV.

​ The client said that they had sexual relationships with 5 women, one with whom they

wanted to marry. They also said that they had once called over a sex worker at their home,

but they expected the sex worker to not take money due to the intimacy that the client felt in

their physical interaction.

G. Summarization

The client is a 54 year old male who has been admitted to Regional Mental Hospital (Thane)

repeatedly for 8 years for excessive talking, aggressiveness, and erratic talking. There is a

possibility that they might have had an appendix removal surgery (no medical record but the

patient was able to show a surgical scar). The client has lived with a large family due to their

father marrying twice, but said that they have mostly have had positive relations with

everyone in the family. The client has not reported any major developmental delays, but has

reported that they believe that people on TV talk to them.

A.​ Appearance

1.​ Personal Identification: The client was cheerful when they greeted the

interviewer. They said that they were happy someone came to visit them

because their family hasn’t, for a long time. Some transference might have

occured because the client said that the interviewer looked similar to their

nephew. They seemed ingratiating, playful, and cooperative.

2.​ Behavior: No abnormalities were seen the client’s posture or gait. They

seemed to, at one point, not be able to control their drooling.

3.​ General Description: The client was well groomed, looked appropriate for

their age, even well built, talked with ease with the interviewer. The client did

not express any inappropriate facial expression during the interview.

B.​ Speech

The client’s speech was at a normal pace, with no abnormalities in its pitch or

loudness. The client very frequently broke into songs.

C.​ Mood and Affect

The client said that they were feeling anxious, anhedonic, and lonely. They had a

broad range of affect which changed often with the content of the conversation, but it

was always appropriate to the content of the conversation.

1.​ Form of Thinking

a.​ Productivity: There was a paucity of ideas related to self but

overabundance of ideas pertaining film references.

b.​ Continuity of Thought: Continuity in thought could not be seen. The

client was able to answer the question asked but there was a constant

derailment of conversations into songs which seemed relevant to the

topic of the conversation but was directionless. A lot of tangentiality

could be seen.

c.​ Language: There was no disorder in language. Sentence formation and

use of words were appropriate and correct.

2.​ Content of Thinking

The client believed that they had a terminal illness and also were in for capital

punishment. They said they were not eating because they thought they were

going to be sentenced to hanging if they eat (an obsessive-compulsive pattern

of preoccupation with getting capital punishment and a compulsive act of not

eating food to prevent it). They also often interjected with requests to not send

them for ECT.

3.​ Thought Disturbances

a.​ Delusions: The client believed that they were going to get capital

punishment (hanging). They also said that they believe that

personalities on TV are talking to them.

how their ideas began, however it seems like what they see on TV has

heavily influenced their thoughts.

4.​ Perceptual Disturbances

a.​ Hallucinations and illusions: The client has said they are being told

that they are going to get capital punishment which they believe in and

thus have formed a delusion too. However the hallucination does not

seem as strongly present as the client’s willingness to believe ti and

elaborate on that belief.

b.​ Depersonalization and Derealization: No depersonalization or

derealization was experienced by the patient.

5.​ Dreams and Fantasies

a.​ Dreams: The patient has not been able to recall any dreams.

b.​ Fantasies: The patient has not expressed any fantasies.

E.​ Sensorium

1.​ Alertness

The patient seemed aware of their surroundings and the people around them.

2.​ Orientation

a.​ Time: The patient seems to have a general track of time, however they

seemed to be unable to keep a precise track of days and date.

c.​ Person: The patient knew who their mental health personnel was. They

were did not seem highly aware about the authority figures in their

ward, however they seemed to be aware of the hierarchy between the

patient and authority figures. They had a good understanding of the

limitations of the role of their assigned mental health personnel who

noted the current case history.

3.​ Concentration and Calculation

The patient had poor concentration. They also performed poorly in digit span

tasks (could only recall 2 digits in a digit forward task and refused to do the

digit backwards task). The could recite tables of 2, 6 and 9, however their

calculation abilities could not be measured because they said they could not do

it. There was an overall general uncooperativeness on behalf of the client to do

tasks pertaining measurement of their calculation abilities, which they

attributed to their medications.

4.​ Memory

The client seemed to have poor long term memory. They could not recall with

much detail events from their past, and they got the years all mixed up.
 5.​ Fund of Knowledge

The client only studied till their 6th Standard and thus their fund of knowledge

based on formal education cannot be expected to be too high. They seemed to

have a higher than average fund of knowledge when it came to Bollywood.

6.​ Abstract Thinking

The client did not show much impoverishment in abstract thinking during the

case history interview.​

F.​ Insight

The client has intellectual insight and has admitted that they have a problem. However

they do not seem to be aware of what they can do about it or have the motivation to

deal with it.

G.​ Judgement

1.​ Social Judgement: The client’s social judgement seems below average. They

are able to hold an animated conversation , however they seem to have had

failures in the past in terms of navigating through social norms.

2.​ Test Judgement: The client fared poorly in tests of social judgement.When

asked what they would do if they found a letter with stamp on it, they said that

they would deliver it to the address on the letter. When asked what they would

do if the address is of a place not reachable by local transport,they said they

would still go to that place.

The following psychodiagnostic tools were used to understand the client’s conscious and

unconscious drives, and to assess their current levels of severity of problems:

1.​ Scale of Assessment of Positive and Negative Symptoms (SAPS and SANS) showed

high ratings on delusional symptoms of the client, particularly grandiose delusions

and delusions of reference,derailment, and anhedonia-asociality items.

2.​ To understand why the client is experiencing anhedonia-asociality, and to tap into the

client’s interpersonal needs and functioning, the Thematic Apperception Test (TAT)

was conducted. The client’s performance revealed the client’s need for nurturance,

affectional relationship, and dependability.

3.​ The Rorschach Inkblot Test was used to understand the functioning of the client on a

perceptual and emotional level, to see how their needs and drives are affecting them.

The test results revealed serious perceptual distortions, a presence of awareness of

unconscious drive, and need for better interpersonal relationships., which also

correlates, on the interpersonal part, with results from the TAT.

4.​ The client was asked to participate in a Draw-A-Person test (DAP) and indications of

lack of impulse control, disturbance in thought, depressed mood, and unhappiness

with the current state of interpersonal relationships were seen in the client’s drawings.

IV. DIAGNOSIS

The client can be assigned a diagnosis of Schizophrenia [295.90 (F20.9)], Multiple

episodes, currently in partial remission because the client exhibits delusions, derailment,

and negative symptoms which is causing significant impairment in their functioning but the

symptoms and the impairment are not severe enough for them to indicate an active phase.
The reason a diagnosis of Schizophreniform Disorder is not given because the MSE notes in

the case file of the client confirms that the symptoms have been present for more than 6

months. Even not warranting a diagnosis, there is clinically significant depressed mood

specifically due to being homesick and the client’s relatives not coming to meet them.

V. PROGNOSIS

Prognosis is not favorable for the client’s psychosis. However, they can certainly be taught

adaptive skills.

VI. PSYCHODYNAMIC FORMULATION

The client seems to be experiencing severe fragmentation of their ego which has resulted in

distorted perception. The underlying causes for this distortion is too deep in the unconscious

since the onset of the problem has taken place da few decades ago. The client’s id craves

affectional fulfillment, however due to being in a hospital setup and infrequent visits by loved

ones seem to further put undue pressure on an already fragmented ego which gets manifested

in form of bizarre behavior and more distortions in thought.

VII. TENTATIVE TREATMENT PLAN

The client will need to continue being on medications to maintain some stability of mind and

be at a better level of functioning. Alongside it would seem that the client is a keen conversor,

and thus supportive psychotherapy might be effective for them. Due to depleted intellectual

capacity, behavioral therapies might work better with the client than talk therapies. The client

would greatly benefit from social skills training which will help them fulfill their

interpersonal needs better. The client also seems to be experiencing a need to be productive,
and thus Occupational Therapy where they learn some skills for some basic income could

make them feel purposeful and dependable.

​ The client’s family needs to be given psychoeducation about how they could handle

impulsive episodes of the client when they are experiencing grandiose delusions or delusions

of reference. Having a to live and look after family member with a mental health issue with

poor prognosis is stressful, thus family therapy could be used as a form of group therapy for

family members of the client’s family to be able to handle this situation.