CASE CONFERENCE

15.03.23
Chairperson : Dr. Sidharth Arya
Co-Ordinator : Dr.Jagriti
Presenters : Dr. Rohit Tiwari
: Dr Dinesh Rohilla
: Mr Sunil
 Aim
• To discuss psychopathology of an adult male presenting with psychotic
illness.
 SOCIO-DEMOGRAPHIC PROFILE
• Mr. S, 35 years old Hindu married male, graduate in Bachelor of Arts,
currently employed as government employee in Rohtak court, belonging
to Hindu joint family of middle socioeconomic status of rural background
of Rohtak, Haryana
Informants:
 Self
 Patient’s wife: 36 years old, clerk in school
 Old records

 Information is adequate and reliable

 CHIEF COMPLAINTS:
According to patient:
Koi dikkat nhi hai mujhe

According to attendant :
1.Khud se badbadate rhte hai
2.Ajeeb vyavhar karte hai
3 ½ years
3.badi-badi baatein karte hai x 2 ½ years
4.Gussa –maar peet karte hai x 4 months
• Total duration of illness : 3 ½ years
• Onset : Insideous
• Course : Continous

• Admitted under Section 89 MHCA 2017.

 History of Present Illness
• To be discussed
 PAST HISTORY
• No h/s/o TB, HTN, Epilepsy, Jaundice, Seizure disorder, Asthma,Thyroid
dysfunction.
• No past history of any surgeries performed.
• No h/o psychiatric illness in past.
 Treatment History
• 2019- Sought treatment from Psychiatry OPD, PGIMS, Rohtak – no documents
available; continued medicines for ~3days.
• 2021-Patient was admitted in Pvt DDC for 15 days and was discharged on same :
Tab. Divalproex 750mg BD
Tab. Risperidone 3mg BD
Tab. THP 2mg OD
Tab. Clonazepam 0.5mg HS
Discontinued medication after 1 week.
FAMILY HISTORY
 Patient belongs to a Hindu joint family of MSES residing in rural background
of district Rohtak.
 He currently resides with his mother, wife and younger daughter.
 Elder daughter is living with maternal grandparents at Panchkula since 2019 .
 Mother - k/c/o Diabetes Mellitus.

 No known history of suicide, abscond, seizure or any psychiatric illness in

family

 Chief care giver–Wife

 Chief earning – Self and wife
 Chief decision maker – Mother
 Attitude of family members towards
illness
The family members considers symptoms due to mental illness and brought
the patient for treatment. They believe that it can be treated with the help of
a psychiatrist.
 Personal History
 Birth history
 Full term vaginal delivery at home .
 No antenatal or postnatal complications.
 No Developmental delay.

 Behaviour and physical illness during childhood

 No history of sleep disturbance, temper tantrums, thumb sucking, nail biting, bed wetting, stammering, tics and mannerisms
and fear-states.
 No history of childhood medical illness.
 No history of repeated lying, destructiveness to property, defiant provocative behavior, persistent disobedience, initiated
fights.
 No h/o impaired attention/overactivity.
 Educational history
 Patient started schooling at 5 years of age.
 Patient graduated 10th standard in 2006 .
 Patient graduated 12th standard in 2008 .
 Patient completed graduation in Bachelor of Arts in 2011.
 Average scholastic performance.
 No history of bunking/ bullying/ complaints from school.
 Occupational History
 Employed as clerk in Intelligence Bureau in 2015.
 Then in 2016 at District Court Rohtak as Assistant Alahmad and working since

 Marital History
Married in 2016
Non- consanguineous marriage.

IPR issues with wife.

 Sexual History
• Sexual knowledge acquired by friends in school at 14 years of age.
• H/o multiple partners.
• H/o paid sex or visits to female sex workers.
• Increased libido and increased frequency of sexual intercourse with wife
from last 4 months.
Substance History:
1. Cannabis (sulfa)
-Use since 16 years
-As per patient- first tried in 2007 after passing 12th standard, then continued taking in form of 1-2 paper
rolls per month.
- Increased use from 2019, once in a week
-May 2021 : got admitted in a private deaddiction centre at Panchkula.
-Current usage : occasional intake in form of 1-2 rolls in a month.
-Last use – 1 day before admission

Opioid (chitta)
-As per patient - started using in July 2022 in a group of friends.
-Mode :I/V drug use and chasing. Once in a week. Quantity not known
- Last intake -1 week back before admission .
Alcohol
-Occasional use of alcohol in social gatherings
-Last intake : 1 months back ; IMFL ~60-90ml

Tobacco
-Chronic smoker since 15 years.
-Cigarette smoking- 4-5 cigarette daily.
-Dependence pattern present.

Legal history – nil

 Pre-Morbid Personality
• Interpersonal relations – Had cordial relations with parents and other family members, relatives,
neighbors and friends.
• Attitude to self and others – confident, respect everyone, obedient towards elders.
• Attitude towards work and responsibilities – handled responsibilities which were assigned to him.
• Religious Belief –performed rituals with parents and occasional temple visits.
• Leisure Time- conversing with family members, visiting relatives, playing with friends.
• Stress coping abilities- normal
• Mood- Predominantly euthymic.
Well adjusted pre-morbid personality.
 General Physical Examination
Patient is conscious, cooperative well built. General condition appears fair.

 Weight— 70kgs Height—172cm BMI – 23.8 kg/m2

 Needle marls on b/l cubital fossa

Vitals:

• Pulse Rate- 80 bpm, regular in rhythm, normal volume, normal character, both upper and lower
limbs,peripheral pulses felt equally
Blood Pressure- 112/76 mmHg
Respiratory Rate- 14 per min, regular in rhythm

 No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal oedema.

 Systemic Examination
Cardio-vascular system:
 Inspection- no deformity or bulging present, apical impulse seen, no
engorged veins.
 Palpation- apex beat on left 5th intercostal space on MCL and tapping in
character. Carotid pulsation felt. No thrills felt in any other areas and in
carotid arteries.
 Auscultation- S1, S2 heard, no murmurs or other adventitious sounds heard

in any area or over carotid arteries.

Respiratory system:
 Inspection- shape of the chest: B/l symmetrical; respiratory rate- 14 per minute, regular in rhythm,
normal breathing pattern B/l movement of chest; No accessory muscle usage; no wheezing or stridor
heard; no sinus, scars, or local erythema seen; no vertebral deformities or bulging present; no
engorged veins.
 Palpation- no local rise of temperature or tenderness, trachea midline; B/l chest symmetrical
movement.
 Percussion: B/l resonant.
 Auscultation- B/l normal vesicular breath sounds heard, no other adventitious sounds heard.
Per abdomen examination:
 Inspection- shape of the abdomen: scaphoid; flanks not full; umbilicus-
midway between xiphisternum and symphysis pubis; no sinus, scars,
pigmentation or local erythema seen; no engorged veins; hernial sites
normal.
 Palpation- no local rise of temperature or tenderness, no organomegaly; no
inguinal lymph node enlargement.
 Percussion: tympanic note.
 Auscultation- bowel sounds heard.
Central nervous system:
Patient is conscious, cooperative.
No signs of neck rigidity.
Cranial nerve examination normal.
Steady gait and posture. No signs of autonomic disturbances. No signs of cerebellar dysfuncton

Right left
Upper limb Lower limb Upper limb Lower limb
Motor functions:
Bulk normal Normal normal Normal
Tone normal normal normal Normal
Power 5/5 5/5 5/5 5/5
Sensory normal normal normal normal
REFLEXES Right left

Superficial:
abdomen ++ ++
Plantar Flexor response Flexor response

Deep tendon
reflexes:
Biceps ++ ++

Triceps ++ ++

Knee jerk ++ ++

Ankle jerk ++ ++
 MENTAL STATE EXAMINATION

 General appearance and behaviour-

An average built male looking of stated age, entered the interview room in a
steady gait and balanced posture along with his wife, greeted the interviewer
on being greeted, dressed appropriately as per socio-cultural norms, hygiene
maintained. Hallucinatory behaviour was observed during the interview.
 Eye to eye contact: made and maintained.
 Rapport: established
 Psychomotor activity: normal
 Reaction time : normal
 Speech - Increased rate, Normal tone and volume. Comprehensible and coherent
Spontaneous as well as in response to questions
 Mood and Affect – (Subjective)theek
(Objective) Blunt, restricted range, inappropriate

 Thought – Form - speech sample

Stream - NAD
Content – speech sample
Q. Namaste Sandeep kaise ho aap?
A. Mai bilkul theek hu.

Q. Hospital kaise aana hua?

A.Hospital toh jabardasti aana pada. Agar aap mujhe smajh sako toh aapko bhi pta lgega Sandeep kaisa aadmi h. Agr mai btau kya
feel kia h maine. Mai bhi court me kaam krta hu. Aap inke jaisa mt samajhna. Maine universe ka formula nikala hai. Universe ka
radius 4750 crore km h aur sun aur earth ka distance 15 crore km h. Aur hum sun ko dekh paate h toh 4750/15=316.66. Toh hume
universe ka 316 hissa toh dikhna chahiye par nhi dekh pate. kyu? Ye sochna aap. GOD is generator operator destroyer, but maine
isme M laga diya means Modifier. Mai modifier hu. Maine shiv ji ki aura ko feel kara hai. Shiv ji ko bhi chota bana diya. Saare bol
pade Sandeep alag aadmi h. Aur ek baat suno aap, humans me XX and XY hota h na. Meri right side ki body X h jisse sara universe
chal raha h aur left bhi X h, pehle y tha, wo chodo aap alag kahani h wo, toh mai ye keh ra tha dusre X yani left X aurat k janam k
liye h. Meri protection me 2 log chalte h meri shadow bnke but ab mujhe pata chl gya h aisa nhi h.

Q. Maine kya pucha tha aapse?

A. Yhi ki hospital kyu aae.
Impression- Derailment, Loss of goal
Q. Aap ye bata rahe h aapki protection me 2 log chalte h? Ye 2 log kon h?
A. Ek Pallavi arora mam h jo ki judge h punchkula me aur ek balram h Pradhan
humare gaon ka.
Q. Ye aapko protection kaise de rahe h?
A. Pallavi madam ko ek baar ankh dikha di thi maine court me tab wo chair pe
peeche ki taraf hokar baith gai thi. Shant ho gayi thi. Mai jab court room me enter
karta tha toh wo kabhi mujhe aise peeche mud ke nahi dekhti thi
Q. Par mai toh protection k baare me puch raha hu. In baton ka usse kya
sambandh hai?
A. Wahi bata raha hu apko wo shant hoke baith gyi thi aur mujhe tedhi nazron se nhi
dekha iska matlab wo bhi meri respect krti h mere aage nhi boli wo toh meri
protection hi kar rahi hai.
Q. Balram aapki protection kaise kr rahe hai?
A. Ek baar wo mujhe bheed me mile the tb unhone kaha tha ki humare gaon
k naujawan ladke kaafi honhaar hai. Toh wo bhi meri protection hi kar
rahe hai.

Q. Protection se kya matlab hai aapka?

B. Protection matlab bure logo se protect karna.

Q. In baton ka protection se kya link hai?

A. Hai. Ye log meri protection karte hai.

Impression- Illogical thinking

Q. Aap ye XX and XY k baare me thoda aur bataenge?
A. Jaise hum sab me XX and XY hota h waise hi mera right side X h jisse universe bana h aur jo left half
h body ka wo bhi X h use aurat ka janam hota hai.
Q. Mai samajh nahi paya, aap thoda vistaar me btaenge?
A. Apne shiv ki photo nhi dekhi h? usme half male and female h. Usme female ki jagah Parvati ki photo
h. Par mere me dono, male and female mai hi hu. Iska matlb maine shiv ko bhi peeche chod dia h. Maine
shiv ko feel kia h uski aura le li h. Log bhi bol gaye ki isne toh shiv ko bhi dikha diya.
Q. Aap ne shiv ji ki aura feel ki iske baare me smjhaenge?
A. Mai kisi ki bhi aura feel kr leta hu. Unki positive aur negative baatein feel kr leta hu. Shiv ji ko feel
kiya h maine. Mere andar h shiv. Wo bhi mere se haar maan gye. Wo sirf GOD h mai GOD-M hu. Mtlb
modifier. Maine GOD ko bhi modify kr dia. Mai kyu Shiv ko maanu jab mere andar shiv h.
Q. Aapko aisa kyu lagta h aapke andar shiv h?
A. Mere left pair me current mehsoos hua tha. Fir current ki awaz aai thi mera pura sharer kaanp gya tha.
Aur fir mujhe shiv ka bada sa chera dikha tha. Phir mai search krta raha. Ek baar mere saamne saanp rkh
diya tha. Aap btao kya mtlab ho skta hai? Iska yhi malab h ki unko pata hai ki maine shiv ko bhi kaabo kr
rkha hai kyuki shiv ji k gale me bhi saanp hota h.
Q. Par iska ye mtlab kaise hua ki aapne shiv ji ko kaabo kar rakha hai?
A. Iska yhi toh mtlab hai warna koi aisa kyu krega. Koi aur hota toh ghabra jata. Logo ko pata hai
tbhi toh mere se ulajhte hai.
Q. Aap bta rhe h ki aapne GOD ko bhi modify kr diya h ye kaise kiya h aapne?
A. GOD k aage M for modifier laga diya maine. Ye sabit kr diya ki GOD bhi kuch nhi h. Maine shiv
banke Corona bhi le aaya aur fir usko khatam bhi kr diya. Humare yha jaat ko sabse upar mana jata h
aur mere aage jaat bhi kuch nahi bolte. Mai Rocky ranveer singh aur Randeep hooda se bhi powerful
bn gya kyuki mere name me bhi R hai (Sandeep Rathee).
Q. Corona to ek failne waali saas ki bimari h, aap aisa kyu maante h ki aapne corona failaya
hai?
A. Mujhe toh kuch pata hi nhi tha baad me pata chala jb log mujhe parakhne lg gye. Logo ko
dikhane k liye krna pada. Fir khatam bhi krwa diya maine. Aage aisa nhi hone dunga. Mai weather
bhi control kar leta hu. Baki log kaha aisa kr sakte hai. Aap ye dekho pichle ek mahine me barish nhi
hui. Jab honi hogi mai bata dunga.
Q. Aap weather kaise control kr lete hai?
A. Shiv ki aura se. Aap newspaper nikal k dekh lo pichle ek mahine ka ek baar bhi
baarish nhi hui. Is mahine bhi nahi hogi.

Q. Ye sab aap kaise kr lete hai, aam aadmi k liye aisa bilkul bhi sambhav nhi
hai?
B. Yhi bta raha hu ap mujhe baki logo jaisa mat samjho. Yha bhi logo ko pata h
mai kya hu. Tbhi toh log mere peeche pdte h.

Q. Kya abhi ap aisa kuch kar k dikha sakte h?

A. Abhi mai koi power nahi use kar raha. Abhi mai sirf aapki aura feel kr raha hu.
Uska mai bikul bhi misuse nahi karunga.

Impression- Delusion of grandiosity, special identity and ability

Q. Aap bata rahe the ki log bhi aapke peeche pad jaate hai?
A. Haan peeche pade rehte hai. Aapas me mere baare me batein karte hai. Jahan bhi jaata hu unko
pata rehta hai mera. Par kya kr lenge mai bilkul truth bolta hu. Koi galat baat nhi boli h maine.
Q. Aapko ye kaise pta chalta hai aapke baare me baatein kr rahe h? kya aapne suna bhi h
unko?
A. Pata chal jata hai. Mujhe dekh k ishaare karte h. Kai baar aisa bhi hota hai ki mujhe ghoorne lg
jate h. Mere peeche aake khade ho jate hai. Mai feel kr leta hu ki mere baare me galat soch rahe
hai.
Q. Aapke peeche khade ho jane se aapko aisa kyu lagta hi ki galat soch rahe hai?
A. Peeche kon khada hota h? Jo peeche se kuch galat krne ka soch raha ho. Unnatural sex krna
chah raha ho.
Q. Aisa bhi toh ho skta h ye sirf aapka vaham ho?
A. Nahi mujhe vaham kyu hoga.
Impression- Delusion of reference
Q. Log aapke baare me baat kyu krenge?
A. Kyuki logo ko pta lg gya ki isne toh shiv k bhi ghutne tikwa diye. Iska toh hum
kuch bigaad nhi sakte.
Q. Kya ye log aapko nuksaan bhi pauchaana chahte hai?
A. Nuksaan toh saare hi krna chahte h. Par maine dikha diya h. Mai jab court me bhi
rehta hu toh aankhe dikha deta hu jb koi mere bare me bura sochta h. Meri aura
bohot badi ho jati h uss samay samne waale bhi samajh jata h ki isse ulajhna theek
nhi hai.
Q. Par koi bhi aapko nuksaan kyu pauchana chahega?
A. Kyuki maine logo ko sahi raasta dikaya h, log unnatural sex krte h. Maine unko
unhi k tareeke se krke bataya h. Aur ab mai logo ko mana krta hu. Toh ab sabhi
mere peeche pad gaye h.
Q. Kya aap in logo ko jaante bhi h?
A. Bohot saare h. kuch ko Janata hu but kitne toh aise h jinko mai kbhi mila bhi nhi.
Par mere bare me toh sabko pata hai.

Q. Kya kisi ne kabhi nuksaan pauchane ki kosish bhi ki hai?

B. Bohot baar kosish karte hai par kar nhi paate. Bolte rahenge, peeche aake khade
ho jaenge par mai pehle hi sambhal jata hu.

Q. Ye aapka vaham bhi toh ho sakta hai?

C. Mujhe koi vaham nhi hai.

Impression- Delusion of persecution

Q. Aapke ghrwaale bta rahe the aap aksar akele baithe baatein krte rehte hai? Kya
aap iss baare me kuch bataenge?
A. Nhi kuch khaas baat nhi h. Koi kuch galat bolta h toh mai bhi saamne se bol k chup kra
deta hu.
Q. Aisa kon aapke baare me bolta h?
A. Hai kaafi saare log. Bolte rehte h. Gaaliyan dete h.
Q. Kya ye aapke saamne aisa bolte hai?
A. Nahi saamne se bolne ki himmat nhi hai. Mujhe bas inki awwaz sunai deti h. Mai kai
baar dhoondta bhi hu kaha se bol rahe h par milte nhi hai. Kai baar kamre se bahar bhi nikal
k dekha h par koi hota nhi h. Mai bhi ghabra jata tha. Par ab ya toh sun leta hu ya suna deta
hu.
Q. Kis samay aati h ye awaazein?
A. Kisi bhi samay aa jati hai.

Q. Aksar kya bolti h ye awaazein?

B. Mujhe gaaliyaan dete rehte hai. Mai bhi de deta hu.

Q. Kya ye awaazein aapko kuch karne ko bhi kehti hain?

C. Nahi sirf gaaliyan dete rehte h, par han kai baar aisa bhi hota h ki kahi jata hu toh bhole bhole
karke bolne lag jaate hain. Bhole matlab shiv. Yani shiv se bhi bada.

Q. Ye sirf aapko bolte h ya aapas me bhi baat krrte h?

D. Sirf mujhe bolte rehte hai.

Q. Kya aap kabhi inhe rokne ki bhi kosish karte h?

A. Bohot kosish ki h par rukti nahi h.

Impression- 2nd person Auditory hallucinations, commenting type

 Thought - Form - Derailment, loss of goal
Stream - NAD
Content – Delusion of reference, Delusion of
persecution, Delusion of grandiosity, Illogical
thinking
Posession – NAD

 Perception – Auditory hallucination (2nd person –commenting type)

 HIGHER MENTAL FUNCTION
Orientation:
1) Time – अभी क्या समय हुआ है ? = शाम के 5-6 (correct)
आज कौन सा वार है ? शनिवार .
आज क्या तारीख है = 11/03/23
2) Place- किस शहर में हो अभी : Rohtak (correct)
इस जगह का क्या नाम है : PGI
इस ईमारत की कौन सी मंज़िल पे है अभी : pehli (correct)
3) Person- आपके साथ कौन आया है हॉस्पिटल में : wife (correct)
मैं कौन हु : doctor (correct)
Impression- oriented to time, place and person.
Attention and concentration:
Digit span test
FORWARD BACKWARD
1,6 1,6 3,8 8,3
2,5,8 2,5,8 8,3,6 6,3,8
1,4,7,2 1,4,7,2, 2,9,1,4 4,1,9,x
8,1,4,7 8,1,4,7
6,1,4,9,2 6,1,4,9, x

Patient was able to complete till 4 digit forward, 3 digit backward

Serial digit subtraction

(100- 7)= 93,89,82 x
40-3 = 37,34,33,31,28,25,22,19,16,13,10,7,4,1 …completed in 60 sec

Impression :attention could be aroused and sustained.

Memory:
Immediate
Registration- roti, ladki, kursi
Recall: could recall roti, ladki , kursi in 1 min and 5 min

Recent
Told correctly what he had for breakfast and lunch.

Remote
Could tell his birthday and years of major life events correctly.

Impression : intact immediate, recent and remote memory.

Intelligence:
General fund of knowledge-
1. Bharat ki pradhanmantri kaun hai: Narender Modi
2. Harayana ki mukhya mantra kaun hai: Khattar
3. Hamare desh ki rajdhani- delhi
4. Independence day: 15th august
5. Ek darzan matlab: 12
6. 3 nadiyon ke naam: beas, ganga, yamuna
7. 3 Haryana ke sheher : ambala, karnal, rohtak
8. Kitne din hote hai ek saal mein: 365
9. Rashtriya pakshi? X
10. Qutub minar kaha hai ? delhi

Impression- adequate GFK (9/10)

Abstract thinking :
Similarity test

Bird- airplane : Aakash mein udte hai (2)

Seb- kela : fal hai(2)
Pen - pencil : likhne ke kaam aate hain (2)
Bus - car : sadhan hai(2)
Chair- table : lakdi ke hote hain (1)

Score: 9/10
Proverbs

• 9-2-11 hona : bhaag jana

• Haath peela karna : shaadi hona
• Pet mein chuhe koodna : bhookh lgna
• Ullu seedha karna : apna kaam nikalna
• Rai ka pahad: badi baat bnana

Score : 10/10

Impression: intact abstract thinking

Judgement:

Personal-
Aap yaha se ghar jakar kya karoge?
Kaam pe jaunga.

Kya kaam krenge ?

Apne purane kaam pe hi firse join krrunga.

Social- intact
Test-
Fire problem – Agar abhi yaha aag lag jaye toh aap kya karenge?
Mitti aur paani se bujhwane mein madad krdenge.
Letter problem-
Aapko raaste mein ek letter stamp aur ptaa likha, gira hua mil jae, toh aap
kya karenge?
Daak khane mein dalwa denge.

Impression: Intact personal, social and test judgement.

Insight :
Kya aapko lagta hai ki aapko koi bimari hain?
(Laughs) mujhe kuch dikkat nahi

Fir hospital aane ka kya karan hai?

Yeh log laaye hai , mujhe toh koi dikkat nahi lagti.

Kya aapko lagta hai ki aapko koi mansik bimari ho skti hai?
Naah, inko hai.
Firr aap yeh jo dawayi kha rhe the,kis dikkat ke liye hai?
Thoda active rhne ke liye hai .
Insight- 1/5 (complete denial of illness)
 DIAGNOSTIC FORMULATION
A, 35 year old graduate ,employed, married male belonging to Hindu joint family of middle socio-
economic status from rural background presented with history of 3 ½ years duration with insidious
onset, continuous course, precipitated by father’s demise characterised by social withdrawal, muttering to
self, suspiciousness from 3 ½ years, grandiose talks from 2 ½ years, aggressive behaviour and sleep
disturbance from 4 months, with h/o poor compliance to treatment in past with history of tobacco,
cannabinoid, and opioid use with h/o increased libido from last 4 months with well-adjusted premorbid
personality with General Physical Examination and Systemic examination within normal limits with
MSE suggestive of hallucinatory behaviour on observation, with blunt affect, with derailment and loss
of goal in form of thought, with delusion of reference, delusion of persecution and delusion of
grandiosity in thought content with 2nd person auditory hallucinations in perception with Higher mental
functions within normal limits with personal ,social and test judgement intact with Insight 1/5.
 PROVISIONAL DIAGNOSIS
• Organic cause has been ruled out on basis of history, examination and
MSE.
• F20.0 – PARANOID SCHIZOPHRENIA
POINTS IN FAVOUR POINTS AGAINST
Delusion of reference, persecution -
Delusion of grandiosity-special abilities
Formal thought disorder
2nd person auditory hallucination
As per ICD 10 :
(d) persistent delusions of other kinds that are culturally inappropriate and
completely impossible, such as religious or political identity, or superhuman
powers and abilities (e.g. being able to control the weather, or being in
communication with aliens from another world)
(e) persistent hallucinations in any modality, when accompanied either by
fleeting or half-formed delusions without clear affective content, or by
persistent over-valued ideas, or when occurring every day for weeks or months
on end
 DIFFERENTIAL DIAGNOSIS
• F22 – PERSISTENT DELUSIONAL DISORDER

POINTS IN FAVOUR POINTS AGAINST

Delusion of reference, persecution Formal thought disorder
Delusion of grandiosity-special abilities Auditory hallucination
Duration >3 months
• F12.50 – MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE
OF CANNABINOIDES- psychotic disorder, schizophrenia like

POINTS IN FAVOUR POINTS AGAINST

h/o Cannabinoid use Continuous illness
Psychotic symptoms No significant improvement in symptoms
on stoppage of substance.
• ICD -11 • DSM-5
6A20.20 ( Schizophrenia, continuous, currently 295.90 (Schizophrenia, continuous)
symptomatic)

CRITERIA

Thinking- Delusion of persecution

Perception- Hallucination

Volition- loss of motivation

Symptoms for 3 ½ years

Not due to organic cause/substance /medication

use
 FINAL DIAGNOSIS
• F20.0 –PARANOID SCHIZOPHRENIA
• F17.21 – MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF
TOBACCO –Dependence syndrome, currently abstinent but in protected
environment.
• F12.1- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF
CANNABINOIDES – Harmful use.
• F11.1- MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF
OPIOIDS- Harmful use.
 MANAGEMENT ISSUES
• Management of acute symptoms
• Poor compliance
• Poor knowledge about the nature of illness, its course and prognosis
• Care giver burden
• Comorbid substance use
 MANAGEMENT PLAN
 Investigations: Complete hemogram, serum electrolytes, KFT, LFT, FBS,
Lipid profile
 Pharmacological
 Non – pharmacological
 Rating Scale for monitoring : PANSS
 Social support and psychosocial stressors
 Review treatment plan accordingly as per progress of patient.
 INVESTIGATIONS
Hemoglobin 15.7gm %
TLC 10,000
DLC 56,41,2,1,0
Platelet 2 lac
URINE
Sugar Nil
Albumin Nil
Serum electrolytes
Serum Na+ 136 meq/L
Serum K+ 5.0 meq/L
KFT
Serum creatinine 0.9 mg/dl
Serum uric acid 5.6 mg/dl

Thyroid profile T3- 162/ T4- 7.6 / TSH- 2.1

HIV NR
HBsAg ,HCV NR
Fasting Blood Sugar 89 mg%
 WARD PROGRESS
Date TREATMENT PSYCHOMETRIC PROGRESS
TESTING

04/03/23 Tab.Olanzapine 10 mg HS PANSS : Day of admission.

Tab.Clonazepam 0.5mg 1-x-2 P 30
N 12
G 30

09/03/23 ----do--- Improvement in sleep.

13/03/23 ----do--- P 28 Improvement in hostility and sleep.

N 12
S 30
 PHARMACOLOGICAL :

• Tab.Olanzapine 10 mg HS
• Tab.Clonazepam 0.5mg 1-x-2
 NON – PHARMACOLOGICAL :
Psychoeducation of the family members and patient regarding the nature and course of
illness.

Clinical psychology opinion for psychodiagnostics evaluation.

Explaining about the nature of illness to the patient after remission of symptoms.
Advise to continue the medication as advised by the treating doctor & explain about the
importance of compliance for treatment.
 CLINICAL PSYCHOLOGY
• Mr. S, 35 years old Hindu married male, graduate in Bachelor of Arts,
currently employed as government employee in Rohtak court, belonging
to Hindu joint family of middle socioeconomic status of rural background
of Rohtak, Haryana has undergone psychodiagnostics evaluation.
• Test administered : Rorschach Psychodiagnostic test
• Test was administered for diagnostic assessment and psychopathology.
• Behaviour during testing and interview : During interview he was conscious, communicative, cooperative he was well
oriented to time place person. Eye to eye contact made and rapport established.
• Significant finding on the Rorschach test:
1. Response productivity was average (R= 25).
2. Approach was D (dominating) indicating the use of economical ways to deal with the environment.
3. F +% was found to be below average (F+62% ) indicative of below average reality orientation and ego strength.
4. Popular responses were also found to be below average indicative of poor ability to conform to the social conventional
norms.
5. Rejection of Card number 2 indicative of conflict with the female gender.
6. More anatomical and sexual responses indicative of sexual and somatic preoccupations.
7. Dd responses and Eye responses were indicative of suspicious tendencies.
8. Perplexity, rotation of cards, space responses and adjectives were added with the responses is indicative of anxiety features.
9. Vista and texture response were indicative of inner tension, anxiety and need for love and appreciation.
10. Color naming was present.
11. Reference response are also present.

Overall Rorschach findings are suggestive of psychotic features along with anxiety features at present.