INTERNSHIP REPORT (PSY 327)

2024-25

Submitted to: Submitted by:

Department of Psychology Riya Saxena
IIS (Deemed to be) University M.A.Psychology
IISU/2023/ADM
/35287
Roll No: 232319
Case Study: Mukti
PATIENT INFORMATION RECORD
Date: 11/06/24
CRF No: NA
Name (in block letters): MUKTI
Age: 35
Sex: Female
Father's/Spouse's Name:
Education: NA
Occupation: Software Engineer
Marital Status: Single
Religion: Hindu
Mother Tongue: Hindi
Residence: Urban
Family Income: 40,000
Address: NA
Pin code: NA
Contact No.: NA
Email: NA
Source of Referral: NA
Previous consultations/hospitalizations (if any): Yes / No: No

PATIENT'S REPORT
Chief Complaints (Client's Verbatim):
"I feel hopeless in my life, I get aggressive easily, I have anxiety issues, and I can't sleep. I want
reassurance, but I feel like my parents prefer my brother. I can't sit still, and I feel suspicious about
everything."

INFORMANT'S REPORT
Chief Complaints:
 Hopelessness
 Aggressiveness
 Anxiety
 Sleep disturbances
 Relationship problems
Reliability: Good

3P'S
Predisposing Factors:
 Family dynamics (perceived favoritism towards elder brother)
 Possible genetic predisposition to mental illness
Precipitating Factors:
 Recent stressors in personal and professional life
 Family conflicts
Perpetuating Factors:
 Lack of family support
 Ongoing anxiety and paranoia
Modifying Factors:
 Supportive friends or colleagues (if any)
Mode of Onset: Insidious
Course of Illness: Continuous
Progress: Deteriorating

HISTORY OF PRESENT ILLNESS

 Mukti reports a pervasive and persistent mood of hopelessness and anxiety.
 She experiences significant distress in her personal and social functioning, affecting her
relationships with family and friends.
 Biological functioning is impacted; she reports insomnia, decreased appetite, and occasional
gastrointestinal issues.
 Activities of daily living are becoming increasingly challenging, particularly in maintaining
personal care due to mood disturbances.
 Important negative history includes no prior psychiatric treatment or hospitalization.

HISTORY OF PAST ILLNESS (Medical/Psychiatric)

 No significant medical history reported.
 No previous psychiatric illnesses reported.

FAMILY HISTORY
Consanguinity between parents: No
First degree relatives:
 Father: NA
 Mother: NA
 Elder Brother: NA
Genogram: NA
Patient's relationship with family members:
 Strained relationship with parents due to perceived favoritism towards elder brother.
 Limited support from family regarding her mental health.

PERSONAL HISTORY
Birth and Early Development:
 NA
Presence of childhood disorders:
 NA
Home atmosphere in childhood and adolescence:
 NA
Scholastic and extra-curricular activities:
 NA
Vocation/Occupation:
 Software Engineer with a stable job.
Menstrual history:
 Regular cycles, no significant issues reported.
Sexual and marital history:
 Sexually active, no current relationships reported.
Forensic history:
 None reported.
General patterns of living:
 NA
Pre-morbid Personality:
 Generally introverted but capable of social interactions; had a history of anxiety in social
situations.
MENTAL STATUS EXAMINATION
1. GENERAL APPEARANCE AND BEHAVIOUR
 Appearance: Shabbily dressed
 Level of grooming: Inadequate
 Level of cleanliness: Inadequate
 Level of consciousness: Conscious and alert
 Co-operativeness: Cooperative
 Eye to eye contact: Poor
 Gesturing: Limited
 Posturing: Normal
 Other movement: Restless
2. SPEECH
 Initiation: Spontaneous
 Speed: Normal
 Output: Normal
 Pressure of Speech: Normal
 Tone: Normal
 Manner: Inappropriately familiar
3. MOTOR ACTIVITY:
 Increased restlessness, scanning environment.
4. THOUGHT
 Stream: Flight of ideas, tangentiality
 Form: Logical but distracted
 Content: Ideas of persecution, suspicious thoughts about others' intentions
5. MOOD / AFFECT:
 Subjective: Anxious and hopeless
 Objective: Labile affect
 Appropriateness: Inappropriate to context
 Congruence: Incongruent
 Emotional Expression: Blunted
6. PERCEPTION:
 Illusions: None reported
 Hallucination: Auditory hallucinations present, hears voices criticizing her
7. COGNITIVE FUNCTIONS
 Attention/Concentration:Distractible, difficulty focusing
 Orientation:
 Time: Appropriate
 Place: Appropriate
 Memory:
 Immediate: Impaired
 Recent: Impaired
 Remote: Intact
 Intelligence:
 Comprehension: Average
 Vocabulary: Good
 General fund of information: Average
 Abstraction: Concrete thinking
 Judgement:
 Personal: Poor
 Social: Poor
 Test: Poor
 Awareness of abnormal behavior/experience: No
 Attribution to physical cause: No
 Willingness to take treatment: Yes
  Recognition of personal responsibility: No
 Insight: Absent

PROVISIONAL DIAGNOSIS
DSM 5 Axis:
I. Paranoid Schizophrenia
II. NA
III. NA
IV. Psychosocial stressors: Family conflict, relationship issues
V. Global Assessment of Functioning (GAF): NA

FINAL DIAGNOSIS
ICD 10/ DSM:
 F20.0 Paranoid Schizophrenia

RECOMMENDATION OF THERAPY
 Initiate antipsychotic medication (e.g., Risperidone)
 Consider psychotherapy (Cognitive Behavioral Therapy)
 Family therapy to address family dynamics
 Regular follow-up appointments to monitor progress
 Encourage participation in support groups for social interaction and support

ASSESSMENT
 Mukti's condition requires a comprehensive treatment plan that addresses both her psychiatric
symptoms and the underlying family dynamics contributing to her distress. Regular
monitoring and adjustments to her treatment plan will be essential for her recovery.

Case Study: Kratika

PATIENT INFORMATION RECORD
Date: 16/06/24
CRF No.: NA
Name (in block letters): KRATIKA
Age: 35
Sex: Female
Father's/Spouse's Name: NA
Education: NA
Occupation: Shop Owner
Marital Status: Widowed
Religion: Christian
Mother Tongue: Hindi
Residence: Urban
Family Income: 50,000
Address: NA
Pin code: NA
Contact No.: NA
Email: NA
Source of Referral: NA
Previous consultations/hospitalizations (if any): Yes / No: No
PATIENT'S REPORT
Chief Complaints (Client's Verbatim):
"I feel anxious all the time, I sweat a lot, and I can't sleep. My eyes are swollen, and I have stomach
aches. I don't want to talk about my husband’s death, and I feel so distant from everyone. I can’t
remember the past year, and I just feel blank."

INFORMANT'S REPORT
Chief Complaints:
 Severe anxiety
 Sweating
 Sleep disturbances
 Swollen eyes
 Stomach aches
 Social withdrawal
 Memory loss
 Increased heart rate
Reliability: Good

3P'S
Predisposing Factors:
 History of trauma from husband's death in a car accident.
 Possible genetic predisposition to anxiety disorders.
Precipitating Factors:
 Sudden death of husband in a traumatic accident.
 Stressful life changes following the loss.
Perpetuating Factors:
 Avoidance of discussing the trauma.
 Lack of social support and connection with others.
Modifying Factors:
 Engagement in hobbies may provide some distraction.
Mode of Onset: Insidious
Course of Illness: Continuous
Progress: Deteriorating

HISTORY OF PRESENT ILLNESS

 Kratika's mood is pervasively anxious and depressed, characterized by a dull, blank
expression and lack of joy.
 Her anxiety has severely impacted her personal and social functioning; she avoids social
interactions and has difficulty managing her shop.
 Biological functioning is affected; she experiences insomnia, loss of appetite, and
gastrointestinal distress.
 Activities of daily living are compromised; she struggles with personal care and maintaining
her shop.
 Important negative history includes no prior psychiatric treatment or hospitalization.

HISTORY OF PAST ILLNESS (Medical/Psychiatric)

 No significant medical history reported.
 No previous psychiatric illnesses reported.

FAMILY HISTORY
Consanguinity between parents: No
First degree relatives:
 Father: NA
 Mother: NA
Genogram: NA
Patient's relationship with family members:
 Close relationship with mother; however, both are struggling to cope with the loss of
Kratika's husband.
 Limited support from father, who may also be grieving.

PERSONAL HISTORY
Birth and Early Development:
 NA
Presence of childhood disorders:
 NA
Home atmosphere in childhood and adolescence:
 NA
Scholastic and extra-curricular activities:
 NA
Vocation/Occupation:
 Owns a small shop; has been less involved since husband's death.
Menstrual history:
 Regular cycles, no significant issues reported.
Sexual and marital history:
 Widowed; husband died in a car accident.
Forensic history:
 None reported.
General patterns of living:
 NA
Pre-morbid Personality:
 Generally sociable, enjoyed engaging with customers in her shop.

MENTAL STATUS EXAMINATION

1. GENERAL APPEARANCE AND BEHAVIOUR
 Appearance: Shabbily dressed
 Level of grooming: Inadequate
 Level of cleanliness: Inadequate
 Level of consciousness: Conscious and alert
 Co-operativeness: Cooperative
 Eye to eye contact: Poor
 Gesturing: Minimal
 Posturing: Normal
 Other movement: Dull, lacks energy
2. SPEECH
 Initiation: Spontaneous
 Speed: Normal
 Output: Normal
 Pressure of Speech: Normal
 Tone:Flat
 Manner: Inappropriately familiar
3. MOTOR ACTIVITY:
 Increased restlessness, fidgeting.
4. THOUGHT
 Stream: Flight of ideas, tangentiality

Form: Logical but distracted

Content: Preoccupied with thoughts of husband's death, anxiety about the future.

5. MOOD / AFFECT:
 Subjective: Anxious, hopeless
 Objective: Blunted affect
 Appropriateness: Inappropriate to context
 Congruence: Incongruent
 Emotional Expression: Blunted
6. PERCEPTION:
 Illusions: None reported
 Hallucination: None reported
7. COGNITIVE FUNCTIONS
 Attention/Concentration:Distractible, difficulty focusing
 Orientation:
 Time: Appropriate
 Place: Appropriate
 Memory:
 Immediate: Impaired
 Recent: Impaired
 Remote: Intact
 Intelligence:
 Comprehension: Average
 Vocabulary: Good
 General fund of information: Average
 Abstraction: Concrete thinking
 Judgement:
 Personal: Poor
 Social: Poor
 Test: Poor
 Awareness of abnormal behavior/experience: No
 Attribution to physical cause: No
 Willingness to take treatment: Yes
 Recognition of personal responsibility: No
 Insight: Absent

PROVISIONAL DIAGNOSIS
DSM 5 Axis:
I. Post-Traumatic Stress Disorder (PTSD)
II. NA
III. NA
IV. Psychosocial stressors: Grief, loss of husband, social isolation
V. Global Assessment of Functioning (GAF): NA

FINAL DIAGNOSIS
ICD 10/ DSM:
 F43.1 Post-Traumatic Stress Disorder (PTSD)

RECOMMENDATION OF THERAPY
 Initiate trauma-focused therapy (e.g., Cognitive Processing Therapy)
 Consider medication for anxiety and depression (e.g., Selective Serotonin Reuptake
Inhibitors)
  Family therapy to address grief and support system
 Regular follow-up appointments to monitor progress
 Encourage participation in support groups for social interaction and support

ASSESSMENT
 Kratika's condition requires a comprehensive treatment plan that addresses both her PTSD
symptoms and the underlying grief and social isolation contributing to her distress. Regular
monitoring and adjustments to her treatment plan will be essential for her recovery. Engaging
her in therapeutic activities and support systems will help her process her trauma and rebuild
her social connections.

Case Study: Lakshya

PATIENT INFORMATION RECORD
Date: 22/06/24
CRF No.: NA
Name (in block letters): LAKSHYA
Age: 17
Sex: Male
Father's/Spouse's Name: NA
Education: Completed 12th Grade
Occupation: Student / Aspiring Candidate
Marital Status: Single
Religion: Hindu
Mother Tongue: Hindi
Residence: Urban
Family Income: NA
Address: NA
Pin code: NA
Contact No.: NA
Email: NA
Source of Referral: Cousin Sister
Previous consultations/hospitalizations (if any): Yes / No: No

PATIENT'S REPORT
Chief Complaints (Client's Verbatim):
"I don’t know what to do with my life. I’m confused about whether to study Computer Science in
India or abroad. I feel like I overrate my abilities, and I just can’t stick to an exercise routine. I tried
the NDA Navy exam but didn’t pass. I don’t want to talk about it, and I find it hard to express my
feelings."

INFORMANT'S REPORT
Chief Complaints:
 Confusion regarding career path
 Low self-esteem and self-doubt
 Difficulty in maintaining exercise routine
 Recent failure in NDA Navy exam
 Tension with father
Reliability: Good

3P'S
Predisposing Factors:
 Family dynamics, particularly a patriarchal father figure.
 Recent academic pressures and societal expectations regarding career choices.
Precipitating Factors:
 Completion of 12th grade and the need to make immediate career decisions.
 Recent failure in the NDA Navy exam.
Perpetuating Factors:
 Ongoing tensions with father and lack of support from family.
 Difficulty in self-expression may lead to unresolved feelings.
Modifying Factors:
 Engagement in hobbies may provide some emotional relief.
Mode of Onset: Insidious
Course of Illness: Continuous
Progress: Static

HISTORY OF PRESENT ILLNESS

 Lakshya presents with a pervasive mood of confusion and anxiety regarding his future career.
 His self-esteem issues impact his personal and social functioning, leading to withdrawal from
peers.
 Role functioning is affected; he is struggling to maintain focus on studies and exercise.
 Biological functioning appears stable; no significant sleep or appetite issues reported.
 Activities of daily living are minimally affected; he maintains personal care but lacks
motivation for exercise.
 Important negative history includes no prior psychiatric treatment or hospitalization.

HISTORY OF PAST ILLNESS (Medical/Psychiatric)

 No significant medical history reported.
 No previous psychiatric illnesses reported.

FAMILY HISTORY
Consanguinity between parents: No
First degree relatives:
 Father: NA
 Mother: NA
 Siblings: NA
Genogram: NA
Patient's relationship with family members:
 Strained relationship with father due to patriarchal attitudes.
 Supportive relationship with mother, though limited in addressing conflicts with father.

PERSONAL HISTORY
Birth and Early Development:
 NA
Presence of childhood disorders:
 NA
Home atmosphere in childhood and adolescence:
 Tension in the household due to father's attitudes; mother often undervalued.
Scholastic and extra-curricular activities:
 Active in school; involved in various clubs but struggles with commitment.
Vocation/Occupation:
 Student preparing for further education.
MENTAL STATUS EXAMINATION
1. GENERAL APPEARANCE AND BEHAVIOUR
 Appearance: Normal
 Level of grooming: Adequate
 Level of cleanliness: Kempt
 Level of consciousness: Conscious and alert
 Co-operativeness: Cooperative
 Eye to eye contact: Good
 Gesturing: Minimal
 Posturing: Normal
 Other movement: Relaxed
2. SPEECH
 Initiation: Spontaneous
 Speed: Normal
 Output: Normal
 Pressure of Speech: Normal
 Tone: Neutral
 Manner: Normal
3. MOTOR ACTIVITY:
 Normal, no signs of agitation or restlessness.
4 . THOUGHT
 Stream: Logical but occasionally distracted
 Form: Coherent
 Content: Preoccupied with career choices and self-doubt.
1. MOOD / AFFECT:
 Subjective: Confused, relaxed
 Objective: Appropriate affect
 Appropriateness: Congruent
 Congruence: Congruent
 Emotional Expression: Relaxed demeanor, though underlying tension present.
2. PERCEPTION:
 Illusions: None reported
 Hallucination: None reported
3. COGNITIVE FUNCTIONS
 Attention/Concentration: Generally intact, though occasionally distracted by
worries about the future.
 Orientation:
 Time: Appropriate
 Place: Appropriate
 Memory:
 Immediate: Intact
 Recent: Intact
 Remote: Intact
 Intelligence:
 Comprehension: Good
 Vocabulary: Good
 General fund of information: Average
 Abstraction: Normal
 Judgement:
 Personal: Average
 Social: Average
 Test: Average
 Awareness of abnormal behavior/experience: No
 Attribution to physical cause: No
  Willingness to take treatment: Yes
 Recognition of personal responsibility: Yes
 Insight: Present

PROVISIONAL DIAGNOSIS
DSM 5 Axis:
I. Adjustment Disorder with Anxiety
II. NA
III. NA
IV. Psychosocial stressors: Family tension, academic pressure
V. Global Assessment of Functioning (GAF): NA

FINAL DIAGNOSIS
ICD 10/ DSM:
 F43.22 Adjustment Disorder with Anxiety

RECOMMENDATION OF THERAPY
 Individual counseling to explore career options and self-esteem issues.
 Family therapy to address communication and relational dynamics, particularly with the
father.
 Encourage participation in extracurricular activities to build confidence and social skills.
 Regular follow-up appointments to monitor progress and adjust the treatment plan as needed.
 Suggest mindfulness or relaxation techniques to help manage anxiety.

ASSESSMENT
 Lakshya's case highlights the need for support in navigating his career choices and addressing
self-esteem issues. The family dynamics, particularly the relationship with his father, play a
significant role in his current state. A comprehensive approach involving individual and
family therapy will be beneficial in helping him gain clarity and confidence in his future
decisions

Case Study: 32-Year-Old Woman Preparing for

Competitive Exams
PATIENT INFORMATION RECORD
Date: 26/06/24
CRF No.: NA
Name (in block letters): NA
Age: 32
Sex: Female
Father's/Spouse's Name: NA
Education: MCom
Occupation: Student (Preparing for Competitive Exams)
Marital Status: Unmarried
Religion: Hindu
Mother Tongue: Hindi
Residence: Urban
Family Income: NA
Address: NA
Pin code: NA
Contact No.: NA
Email: NA
Source of Referral: NA
Previous consultations/hospitalizations (if any): Yes / No: No

PATIENT'S REPORT
Chief Complaints (Client's Verbatim):
"I feel so anxious about the upcoming exams. I put so much pressure on myself to be perfect, but it
leads to sleepless nights and mental blocks. I did well in mock tests, but during the real exam, I
couldn't recall answers, and it affected my interview. I get irritated when people tell me to stop
worrying."

INFORMANT'S REPORT
Chief Complaints:
 Heightened anxiety related to competitive exam preparation
 Perfectionism leading to mental blocks and sleeplessness
 Irritability and anger towards others' advice
 Social isolation from friends
Reliability: Good

3P'S
Predisposing Factors:
 Perfectionistic tendencies
 Previous negative experiences with exams (recall issues)
Precipitating Factors:
 Upcoming competitive exams
 Pressure from peers and boyfriend, who are also preparing for the same exams
Perpetuating Factors:
 Social isolation from friends
 High self-imposed expectations
Modifying Factors:
 Active engagement in yoga and self-care routines
Mode of Onset: Insidious
Course of Illness: Continuous
Progress: Deteriorating as exam date approaches

HISTORY OF PRESENT ILLNESS

 The patient exhibits a pervasive mood of anxiety, particularly as the exam date approaches.
 The anxiety impacts her personal and social functioning, leading to isolation from friends and
irritability with family members.
 Role functioning is affected; she dedicates excessive hours to studying (7-8 hours daily) and
struggles to balance social interactions.
 Biological functioning is compromised; she experiences sleeplessness and mental blocks.
 Activities of daily living are maintained, but social interactions are limited.
 Important negative history includes no prior psychiatric treatment or hospitalization.

HISTORY OF PAST ILLNESS (Medical/Psychiatric)

 No significant medical history reported.
 No previous psychiatric illnesses reported.

FAMILY HISTORY
Consanguinity between parents: No
First degree relatives:
 Father: NA
 Mother: NA
 Sister: NA
Genogram: NA
Patient's relationship with family members:
 Generally supportive relationship with sister, who provides insights into her behavior.
 Possible pressure from parents regarding academic and career success.

PERSONAL HISTORY
Birth and Early Development:
 NA
Presence of childhood disorders:
 NA
Home atmosphere in childhood and adolescence:
 Supportive environment but high expectations from parents regarding academic performance.
Scholastic and extra-curricular activities:
 Active in academics, participated in various extracurricular activities during schooling.
Vocation/Occupation:
 Currently focused on preparing for competitive exams.

MENTAL STATUS EXAMINATION

1. GENERAL APPEARANCE AND BEHAVIOUR
 Appearance: Normal
 Level of grooming: Adequate
 Level of cleanliness: Kempt
 Level of consciousness: Conscious and alert
 Co-operativeness: Cooperative
 Eye to eye contact: Good
 Gesturing: Normal
 Posturing: Normal
 Other movement: Relaxed but occasionally fidgety
2. SPEECH
 Initiation: Spontaneous
 Speed: Normal
 Output: Normal
 Pressure of Speech: Normal
 Tone: Normal
 Manner: Friendly and engaging
3. MOTOR ACTIVITY:
 Normal, but some restlessness noted.
4. THOUGHT:
 Stream: Logical, but occasionally distracted by worries about exams
 Form: Coherent
 Content: Preoccupied with exam performance and perfectionism.
5. MOOD / AFFECT:
 Subjective: Anxious and pressured
 Objective: Appropriate affect
 Appropriateness: Congruent
 Congruence: Congruent
 Emotional Expression: Generally positive demeanor, but underlying anxiety
evident.
 6. PERCEPTION:
 Illusions: None reported
 Hallucination: None reported
7. COGNITIVE FUNCTIONS
 Attention/Concentration: Generally intact, though occasionally impaired by
anxiety.
 Orientation:
 Time: Appropriate
 Place: Appropriate
 Memory:
 Immediate: Intact
 Recent: Intact
 Remote: Intact
 Intelligence:
 Comprehension: Good
 Vocabulary: Good
 General fund of information: Average
 Abstraction: Normal
 Judgement:
 Personal: Average
 Social: Average
 Test: Average
 Awareness of abnormal behavior/experience: Yes
 Attribution to physical cause: No
 Willingness to take treatment: Yes
 Recognition of personal responsibility: Yes
 Insight: Present

PROVISIONAL DIAGNOSIS
DSM 5 Axis:
I. Generalized Anxiety Disorder
II. NA
III. NA
IV. Psychosocial stressors: Academic pressure, social isolation
V. Global Assessment of Functioning (GAF): NA

FINAL DIAGNOSIS
ICD 10/ DSM:
 F41.1 Generalized Anxiety Disorder

RECOMMENDATION OF THERAPY
 Cognitive Behavioral Therapy (CBT) to address anxiety and perfectionism.
 Stress management techniques, including mindfulness and relaxation exercises.
 Encourage social interactions to reduce isolation and improve mood.
 Regular follow-up appointments to monitor progress and adjust the treatment plan as needed.
 Suggest maintaining a balanced study schedule to prevent burnout.

ASSESSMENT
 The case of the 32-year-old woman highlights the impact of perfectionism and anxiety on her
exam preparation and overall well-being. Addressing her anxiety through therapy and
promoting a balanced approach to studying will be crucial in helping her achieve her goals
while maintaining her mental health.
Case Study: Individual with Anxiety About Going Out
PATIENT INFORMATION RECORD
Date: 21/06/24
CRF No.: NA
Name (in block letters): NA
Age: NA
Sex: Male
Father's/Spouse's Name: NA
Education: NA
Occupation: NA
Marital Status: NA
Religion: Hindu
Mother Tongue: Hindi
Residence: Urban
Family Income: NA
Address: NA
Pin code: NA
Contact No.: NA
Email: NA
Source of Referral: NA
Previous consultations/hospitalizations (if any): Yes / No: No

PATIENT'S REPORT
Chief Complaints (Client's Verbatim):
"I feel anxious about going out. I constantly rely on my earphones and phone for comfort. After my
business loss, I’ve been under so much stress, and it feels overwhelming. I sweat a lot and can’t seem
to keep track of time; I keep looking at my watch and feel restless."

INFORMANT'S REPORT
Chief Complaints:
 Anxiety about going out
 Reliance on earphones and phone for comfort
 Continuous stress following business loss
 Frequent sweating and feelings of being overwhelmed
 Restlessness and low voice
Reliability: Satisfactory

3P'S
Predisposing Factors:
 Previous business loss leading to financial stress.
 Possible underlying anxiety disorder.
Precipitating Factors:
 Recent business failure and associated financial pressures.
 Increased responsibilities and expectations in business.
Perpetuating Factors:
 Continuous stress without effective coping mechanisms.
 Reliance on technology (earphones and phone) to cope with anxiety.
Modifying Factors:
 Support from friends or family may help mitigate anxiety.
Mode of Onset: Acute
Course of Illness: Continuous
Progress: Deteriorating

HISTORY OF PRESENT ILLNESS

 The patient exhibits pervasive anxiety, particularly related to going out and engaging in social
situations.
 His anxiety significantly impacts personal and professional functioning; he is unable to focus
on work and feels overwhelmed by daily tasks.
 Role functioning is affected; he struggles to maintain business responsibilities and feels
pressure to adhere to strict schedules.
 Biological functioning includes excessive sweating and restlessness; no significant sleep or
appetite issues reported.
 Activities of daily living are maintained, but social interactions are limited.
 Important negative history includes no prior psychiatric treatment or hospitalization.

HISTORY OF PAST ILLNESS (Medical/Psychiatric)

 No significant medical history reported.
 No previous psychiatric illnesses reported.

FAMILY HISTORY
Consanguinity between parents: No
First degree relatives:
 Father: NA
 Mother: NA
 Siblings: NA
Genogram: NA
Patient's relationship with family members:
 Supportive relationship with family, though possible pressure regarding financial stability and
business success.

PERSONAL HISTORY
Birth and Early Development:
 NA
Presence of childhood disorders:
 NA
Home atmosphere in childhood and adolescence:
 Generally supportive, but high expectations regarding success and financial independence.
Scholastic and extra-curricular activities:
 NA
Vocation/Occupation:
 Engaged in business, currently facing challenges due to recent losses.

MENTAL STATUS EXAMINATION

1. GENERAL APPEARANCE AND BEHAVIOUR
 Appearance: Normal
 Level of grooming: Adequate
 Level of cleanliness: Kempt
 Level of consciousness: Conscious and alert
 Co-operativeness: Cooperative
 Eye to eye contact: Poor
  Gesturing: Minimal
 Posturing: Normal
 Other movement: Restless, frequently checking watch
2. SPEECH
 Initiation: Spontaneous
 Speed: Slow
 Output: Low volume
 Pressure of Speech: Normal
 Tone: Flat
 Manner: Inappropriate due to anxiety
3. MOTOR ACTIVITY:
 Increased restlessness noted, frequent fidgeting.
4. THOUGHT
 Stream: Logical but preoccupied with worries about time and business
responsibilities.
 Form: Coherent
 Content: Focused on anxiety related to business and social situations.
5. MOOD / AFFECT:
 Subjective: Anxious and overwhelmed
 Objective: Restricted affect
 Appropriateness: Congruent
 Congruence: Congruent
 Emotional Expression: Generally subdued, with moments of agitation.
6. PERCEPTION:
 Illusions: None reported
 Hallucination: None reported
7. COGNITIVE FUNCTIONS
 Attention/Concentration: Impaired due to anxiety; difficulty focusing on tasks.
 Orientation:
 Time: Appropriate
 Place: Appropriate
 Memory:
 Immediate: Intact
 Recent: Intact
 Remote: Intact
 Intelligence:
 Comprehension: Good
 Vocabulary: Good
 General fund of information: Average
 Abstraction: Normal
 Judgement:
 Personal: Average
 Social: Average
 Test: Average
 Awareness of abnormal behavior/experience: Yes
 Attribution to physical cause: No
 Willingness to take treatment: Yes
 Recognition of personal responsibility: Yes
 Insight: Present

PROVISIONAL DIAGNOSIS
DSM 5 Axis:
I. Generalized Anxiety Disorder
II. NA
III. NA
IV. Psychosocial stressors: Business loss, social anxiety
V. Global Assessment of Functioning (GAF): NA

FINAL DIAGNOSIS
ICD 10/ DSM:
 F41.1 Generalized Anxiety Disorder

RECOMMENDATION OF THERAPY
 Cognitive Behavioral Therapy (CBT) to address anxiety and coping strategies.
 Stress management techniques, including mindfulness and relaxation exercises.
 Encourage gradual exposure to social situations to reduce anxiety about going out.
 Regular follow-up appointments to monitor progress and adjust the treatment plan as needed.
 Suggest developing a structured daily routine to manage time effectively without feeling
overwhelmed.

ASSESSMENT
 The case of the individual with anxiety about going out illustrates the significant impact of
stress and anxiety on daily functioning and social interactions. Addressing his anxiety through
therapy and promoting effective coping strategies will be essential in helping him regain
confidence and improve his quality of life.

Case Study: Person with OCD Symptoms

PATIENT INFORMATION RECORD
Date: 11/06/24
CRF No.: NA
Name (in block letters): NA
Age: NA
Sex: Male
Father's/Spouse's Name: NA
Education: NA
Occupation: NA
Marital Status: NA
Religion: Hindu
Mother Tongue: Hindi
Residence: Urban
Family Income: NA
Address: NA
Pin code: NA
Contact No.: NA
Email: NA
Source of Referral: NA
Previous consultations/hospitalizations (if any): Yes / No: Yes

PATIENT'S REPORT
Chief Complaints (Client's Verbatim):
"I have this constant need to wash my hands and keep my clothes perfectly organized. Even though
I’m usually outgoing and cheerful, my relationships have suffered a lot, especially after the affair with
my sister-in-law. I feel relaxed when I talk, and I just want to keep the conversation going."
INFORMANT'S REPORT
Chief Complaints:
 Compulsive hand washing and need for organization
 Difficulties in relationships, particularly after the affair
 Outgoing and extroverted demeanor masking underlying distress
Reliability: Good

3P'S
Predisposing Factors:
 Possible genetic predisposition to OCD or anxiety disorders.
 History of family conflict or dysfunction.
Precipitating Factors:
 Affair with sister-in-law leading to social disapproval and family conflict.
 Increased stress and anxiety following the affair's discovery.
Perpetuating Factors:
 Ongoing anxiety related to social disapproval and relationship difficulties.
 Compulsive behaviors reinforcing feelings of anxiety and distress.
Modifying Factors:
 Support from friends or family may help mitigate symptoms.
Mode of Onset: Insidious
Course of Illness: Continuous
Progress: Static with episodes of exacerbation.

HISTORY OF PRESENT ILLNESS

 The patient exhibits pervasive anxiety and compulsive behaviors related to cleanliness and
organization.
 His symptoms significantly impact personal relationships, particularly after the affair, leading
to social withdrawal and disapproval from family members.
 Role functioning is affected; he struggles to maintain healthy relationships and feels isolated.
 Biological functioning appears stable; no significant sleep or appetite issues reported.
 Activities of daily living are maintained, but social interactions are limited and strained.
 Important negative history includes no prior psychiatric treatment or hospitalization.

HISTORY OF PAST ILLNESS (Medical/Psychiatric)

 No significant medical history reported.
 No previous psychiatric illnesses reported.

FAMILY HISTORY
Consanguinity between parents: No
First degree relatives:
 Father: NA
 Mother: NA
 Siblings: NA
Genogram: NA
Patient's relationship with family members:
 Strained relationship with family following the affair; possible support from friends.

PERSONAL HISTORY
Birth and Early Development:
 NA
Presence of childhood disorders:
  NA
Home atmosphere in childhood and adolescence:
 Generally supportive but possible underlying tensions regarding family dynamics.
Scholastic and extra-curricular activities:
 Active in school; involved in various clubs and social activities.
Vocation/Occupation:
 NA

MENTAL STATUS EXAMINATION

1. GENERAL APPEARANCE AND BEHAVIOUR
 Appearance: Normal
 Level of grooming: Adequate
 Level of cleanliness: Kempt
 Level of consciousness: Conscious and alert
 Co-operativeness: Cooperative
 Eye to eye contact: Good
 Gesturing: Frequent and animated
 Posturing: Normal
 Other movement: Occasionally fidgety
2. SPEECH
 Initiation: Spontaneous
 Speed: Normal
 Output: Normal
 Pressure of Speech: Normal
 Tone: Friendly and engaging
 Manner: Inappropriate due to compulsive need to discuss
3. MOTOR ACTIVITY:
 Increased activity noted; some compulsive behaviors observed.
4. THOUGHT
 Stream: Logical but preoccupied with cleanliness and organization.
 Form: Coherent
 Content: Focused on compulsive behaviors and relationship issues.
5. MOOD / AFFECT:
 Subjective: Generally cheerful but underlying anxiety present
 Objective: Affect is congruent with mood
 Appropriateness: Appropriate
 Congruence: Congruent
 Emotional Expression: Expressive and animated, though occasionally anxious.
6. PERCEPTION:
 Illusions: None reported
 Hallucination: None reported
7. COGNITIVE FUNCTIONS
 Attention/Concentration: Fairly intact, though distracted by compulsive thoughts.
 Orientation:
 Time: Appropriate
 Place: Appropriate
 Memory:
 Immediate: Intact
 Recent: Intact
 Remote: Intact
 Intelligence:
 Comprehension: Good
 Vocabulary: Good
 General fund of information: Average
  Abstraction: Normal
 Judgement:
 Personal: Average
 Social: Average
 Test: Average
 Awareness of abnormal behavior/experience: Yes
 Attribution to physical cause: No
 Willingness to take treatment: Yes
 Recognition of personal responsibility: Yes
 Insight: Present

PROVISIONAL DIAGNOSIS
DSM 5 Axis:
I. Obsessive-Compulsive Disorder
II. NA
III. NA
IV. Psychosocial stressors: Affair, family disapproval
V. Global Assessment of Functioning (GAF): NA

FINAL DIAGNOSIS
ICD 10/ DSM:
 F42 Obsessive-Compulsive Disorder

RECOMMENDATION OF THERAPY
 Cognitive Behavioral Therapy (CBT) focusing on exposure and response prevention to
address OCD symptoms.
 Family therapy to address relationship issues and improve family dynamics.
 Encourage participation in support groups for individuals with OCD.
 Regular follow-up appointments to monitor progress and adjust the treatment plan as needed.
 Suggest stress management techniques, including mindfulness and relaxation exercises.

ASSESSMENT
 The case of the individual with OCD symptoms highlights the interplay between compulsive
behaviors and interpersonal relationships. Addressing his OCD through therapy and
improving family dynamics will be crucial in helping him manage his symptoms and enhance
his quality of life