SOCIO-DEMOGRAPHIC DATA

Name: Mrs. S

Age: 38 years

Sex: Female

Education: High School Graduate

Occupation: Homemaker

Annual Income: Dependent on spouse

Marital Status: Married

Residence: Rural

Mother Tongue: Hindi

Religion: Hindu

REFERRAL DETAILS

Referred by a local general physician due to persistent low mood, loss of interest, and suicidal

thoughts.

INFORMANT DETAILS

Name: Mr. S (Husband)

Relationship with client: Husband

Acquaintance: Lives with patient

Adequacy: Good

Reliability: High
PRESENTING COMPLAINTS

 Persistent sadness – 9 months

 Loss of interest in household activities – 8 months

 Fatigue and lack of energy – 7 months

 Sleep disturbances – 6 months

 Suicidal thoughts – 1 month

HISTORY OF PRESENTING ILLNESS

The patient first noticed symptoms six years ago when he developed a persistent fear of germs

and contamination. He began washing his hands frequently, initially thinking it was a hygiene

concern. However, over time, his need to wash increased, and he started avoiding touching

public surfaces or shaking hands with others. Around five years ago, he developed repeated

checking behaviors, such as ensuring doors were locked and gas stoves were turned off multiple

times before leaving home. This significantly increased the time he took to complete daily tasks.

He became distressed if he could not perform these rituals, experiencing heightened unease.

Four years ago, he started experiencing unwanted thoughts about harming his loved ones, even

though he had no intention of acting on them. This led to immense guilt and further reinforced

his need to perform certain actions, as he believed they would help him feel better. His symptoms

worsened over the past two years, severely affecting his ability to function at work. His

productivity declined as he spent extended periods engaged in repetitive behaviors. His wife

reported that he would repeatedly ask for reassurance about cleanliness and safety, leading to
strain in their relationship. He finally sought help when he realized his behaviors were beyond

his control and causing distress to his family.

In recent months, his behaviors have extended to his personal hygiene and grooming routines. He

now spends an excessive amount of time showering, often repeating the process multiple times a

day if he feels he has come into contact with something he considers dirty. He has also developed

specific routines for dressing, such as repeatedly washing and rewashing his clothes or avoiding

certain outfits he feels are unclean. These behaviors have caused significant delays in his daily

schedule, often making him late for work or social commitments. His wife has noted that he

becomes visibly upset if his routines are interrupted or if he is unable to complete them to his

satisfaction.

The unwanted thoughts have also become more frequent and distressing, often involving vivid

mental images of harm coming to his family members or himself. These thoughts are

inconsistent with his values and cause him significant distress. To cope, he has developed new

habits, such as repeating specific phrases or prayers in his mind a set number of times, which he

believes will prevent harm from occurring. However, these habits provide only temporary relief,

and the unwanted thoughts quickly return, creating a cycle of unease and repetitive actions.

His symptoms have also begun to affect his sleep. He often stays up late into the night

performing cleaning rituals or checking locks and appliances, leaving him exhausted the next

day. His wife has observed that he appears increasingly tired and irritable, and he has admitted to

feeling overwhelmed by the constant mental and physical demands of his behaviors. Despite his

exhaustion, he finds it difficult to relax or engage in leisure activities, as his mind is preoccupied

with fears of contamination or harm. This has further contributed to his sense of isolation and has

made it challenging for him to connect with his family or enjoy moments of rest.
The patient has been socially withdrawn since his teenage years, avoiding group activities and

preferring solitary tasks. During his school years, he was often hesitant to ask questions in class

or participate in discussions, fearing he would be ridiculed. His classmates perceived him as shy,

but his parents initially considered it a normal personality trait rather than something to be

concerned about. During his college years, his unease in social situations worsened as he faced

increased academic and social expectations. He struggled to participate in presentations, avoided

making eye contact, and often skipped classes where he was required to engage in discussions.

When forced into social situations, he experienced physical symptoms such as excessive

sweating, trembling, and a racing heart. He started to overthink every interaction, fearing that

others were constantly judging him. As a result, he withdrew further, spending most of his time

in his hostel room or at home during vacations.

Over the past year, his academic performance has declined due to his inability to participate in

group projects and oral examinations. His avoidance of social situations increased, and he began

making excuses to skip social events, fearing he might embarrass himself. He expressed deep

distress about his inability to communicate effectively and felt inferior to his peers. He also

admitted to feeling isolated but was unable to initiate conversations or maintain friendships due

to his overwhelming fear of being judged negatively. His family initially dismissed his struggles,

attributing them to nervousness or a lack of confidence. However, when his college counselor

noted his difficulties and suggested seeking help, his parents decided to take action. He reports

no history of substance use, major stressors, or medical illnesses. However, his mother has a

history of social withdrawal, though she was never formally evaluated for it.

The patient was reportedly functioning well until nine months ago when she started experiencing

persistent sadness, which she initially attributed to increasing household burdens and financial
difficulties. As the eldest daughter-in-law in a joint family, she was responsible for numerous

domestic duties, caring for children, and managing family expectations. She initially dismissed

her symptoms, attributing them to stress and exhaustion. Over the next few months, she lost

interest in routine activities, including cooking and interacting with family members. She

stopped participating in religious and community events, which had previously been a source of

joy. Her energy levels declined significantly, making it difficult for her to complete daily chores.

She felt overwhelmed but was unable to express her distress openly due to fear of being judged

by her in-laws and extended family.

Her sleep became disturbed, and she began waking up in the early hours of the morning, unable

to fall back asleep. Her appetite reduced significantly, leading to noticeable weight loss. She

often complained of body aches and headaches, for which she frequently visited local healers

and religious practitioners, believing she was under some spiritual influence. However, no

physical cause was found, and her symptoms persisted. One month ago, she began experiencing

recurrent thoughts of death and suicide. She confided in her husband that she felt like a burden to

the family and wished to end her life. She also mentioned feeling worthless, as she believed she

had failed in fulfilling her family responsibilities. Her husband became alarmed when he found

her sitting alone for long hours, weeping uncontrollably. Concerned about her worsening

condition, he took her to a local doctor, who referred her for further evaluation.

There was no prior history of similar episodes, substance use, or major life stressors apart from

family-related conflicts. A family history revealed that her maternal aunt had suffered from a

similar condition but never received formal treatment.

 No history of manic or psychotic symptoms

 No history of substance use

 No known chronic medical illness

MEDICAL HISTORY

No significant past medical illness, surgeries, or accidents.

PAST PSYCHIATRIC HISTORY

No prior psychiatric hospitalizations or treatments.

FAMILY HISTORY

 History of untreated depression in a maternal relative.

 No history of bipolar disorder or schizophrenia.

Date of Birth: 12th June 1985

Place of Birth: Jaipur, Rajasthan, India

Birth history: Full-term delivery

Delivery type: Normal vaginal delivery

Birth cry: Immediate and normal

Mother’s condition during pregnancy: No significant complications reported during

pregnancy. Mother did not have gestational diabetes, hypertension, or infections.

Postnatal history: No postnatal complications reported. Mother and baby were discharged

within 2 days of delivery.

Physical health during infancy: Generally healthy with no major illnesses. No history of

recurrent infections, feeding difficulties, or hospitalization during infancy.

Delay in milestone development:

 Motor: No significant delay. Started walking independently by 12 months.

 Adaptive: No significant delay. Able to perform age-appropriate self-care tasks (e.g.,

feeding, dressing) on time.

 Speech: No significant delay. Started speaking single words by 12 months and simple

sentences by 2 years.

 Social: No significant delay. Able to interact with family members and peers

appropriately during early childhood.

obsessive-compulsive behaviors during childhood.

Night terrors: None reported.

Behavior problems during childhood: None reported. No history of aggression, defiance, or

conduct problems during childhood.

Habits during childhood: No significant habits reported (e.g., no thumb-sucking, nail-biting, or

bedwetting).

Childhood health: Generally healthy with no chronic illnesses. Experienced common childhood

illnesses (e.g., cold, fever) but no major health concerns.

Home atmosphere during childhood: Satisfactory. The patient grew up in a stable and

supportive family environment. Parents were attentive and caring.

Emotional problems in adolescence: None reported. No history of running away, delinquency,

smoking, drug use, or identity problems.

Home atmosphere during adolescence: Satisfactory. The patient had a supportive family

environment during adolescence.

Parental lack: None reported. Both parents were involved and supportive.

Anomalous family situation: None reported. The family was stable and intact.

EDUCATIONAL HISTORY

Age of beginning school: 5 years old

Special abilities/disabilities: No special abilities or disabilities reported. The patient was an

average student with no significant learning difficulties.

Academic performance: Average. The patient consistently scored average grades throughout

school.
Number of friends: Moderate. The patient had a small group of close friends during school

years.

Relationship with friends: Friendly and supportive. The patient maintained good relationships

with her peers.

Co-curricular activities: Minimal participation. The patient occasionally participated in school

events but showed little interest in sports or arts.

Hobbies and interests: Enjoyed reading and gardening.

OCCUPATIONAL HISTORY

Age of starting work: Not applicable (patient is a homemaker).

Work record: Not applicable.

Past job: None.

Present job: Homemaker.

Job satisfaction: Initially satisfied but has become less so due to depression.

MENSTRUAL HISTORY

Age of Menarche: 13 years old

Regularity/duration: Regular cycles, 28-day cycle, duration of 5 days.

Amount of physical pain: Mild to moderate menstrual cramps.

Emotional problems if any: None reported.

SEXUAL INCLINATIONS AND PRACTICE

Sexual information acquired through: Peers and informal sources (e.g., friends, internet). The

patient did not receive formal sexual education.

Masturbation/sexual fantasies: Occasional masturbation reported, which she considers normal.

Homosexuality/heterosexuality: Heterosexual orientation.

Sexual problems if any: Reduced libido due to depression.

MARITAL HISTORY

Spouse age: 40 years old

Duration of marriage: 15 years

Occupation: Farmer

Personality: Supportive but traditional.

Compatibility: Initially good but has become strained due to the patient’s depression.

PRE-MORBID PERSONALITY

Social relations with:

 Family: Close relationship with parents and siblings.

 Friends: Friendly and supportive relationships with a small group of friends.

 Relatives: Maintained casual relationships with extended family.

 Societies: No active participation in social groups or community activities.

 Workmates: Not applicable (patient is a homemaker).

Intellectual activities like:

 Hobbies: Enjoyed reading and gardening.

 Interests: Limited interests outside of her hobbies.

 Memory: No significant memory issues reported prior to depression.

 Judgement: Fair judgment in everyday matters but became impaired due to depression.

Mood of client:

 Bright/cheerful: Occasionally.

 Despondent: Frequently, especially in the context of depression.

 Optimistic: Rarely.

 Pessimistic: More often, particularly in recent months.

 Self-depreciative: Occasionally, with feelings of inadequacy related to her depression.

 Satisfied: Rarely.

 Stable: Generally stable but with increasing mood fluctuations due to depression.

 Unstable: Became more unstable as depression worsened.

Character:

 Attitude to work and responsibility: Responsible but became neglectful due to

depression.

 Interpersonal relationships: Friendly but became strained due to depression.

 Standards in religious/social/health matters: Moderate. The patient adhered to basic

religious practices but was not deeply involved. Social and health standards were

average.

Fantasy life:
  Frequency and content of day dreaming: Occasionally engaged in daydreaming, often

about escaping her current situation or achieving success.

Habits:

 Eating: Reduced appetite due to depression.

 Alcohol consumption: No history of alcohol use.

 Self-medication: None reported.

 Tobacco consumption: No history of tobacco use.

 Sleeping patterns: Disturbed sleep due to depression (early morning awakenings).

 Excretory functions: No significant issues reported.

 Use of other recreational drugs: None reported.

GENERAL APPEARANCE AND BEHAVIOUR

Appearance: Looking older than her age (due to fatigue and neglect of self-care).

Level of Grooming: Shabbily dressed.

Level of Cleanliness: Inadequate.

Level of consciousness: Fully conscious and alert.

Mode of entry: Came willingly.

Cooperativeness: Normal.

Eye-to-eye Contact: Difficult to maintain.

Psychomotor activity: Decreased (slowed movements and speech).

Empathy: Difficult to establish.

Quality of rapport: Poor.

Posturing: Normal posture.

Other movements: None observed (no mannerisms, stereotypes, tremors, EPS, AIMS, or

perseveration).

Other Catatonic Phenomena: None observed.

SPEECH

Initiation: Speaks when spoken to.

Reaction time: Delayed.

Speed: Slow.

Output: Decreased.

Pressure of Speech: Absent.

Volume: Decreased.

Tone: Monotonous.

Manner: Normal.

Relevance: Fully relevant.

Stream: Normal.

Coherence: Fully coherent.

Others: None observed (no rhyming, punning, echolalia, perseveration, or neologism).

Sample of speech (in response to open-ended questions):

 "I feel so tired all the time. I can’t do anything anymore. I just want to sleep and not wake

up."
THOUGHT

Tempo: Retarded thinking.

Form: Adequate.

Obsession: None observed.

Compulsion: None observed.

Thought alienation phenomena: None observed.

Thought contents:

 Worthlessness: Feels like a burden to her family.

 Hopelessness: Believes her situation will never improve.

 Guilt: Feels guilty for not fulfilling her responsibilities.

 Suicidal Ideas: Recurrent thoughts of death and suicide.

Example: "I’m useless. My family would be better off without me."

IMPRESSION: Not intact

MOOD

Subjective: Sad and hopeless.

Objective:

 Predominant mood state: Depressed.

 Other major moods: Anxious, irritable.

 Range: Restricted.

 Reactivity: Reduced.
  Quality of mood: Dysphoric.

 Communicability: Difficult.

 Lability: Present (frequent mood swings).

 Appropriateness: Appropriate.

 Congruence: Congruent.

 Emotional expression: Blunted.

IMPRESSION: mood is congruent with affect

PERCEPTION

Hallucination: None observed.

Illusion: None observed.

Depersonalization: None reported.

Déjà vu phenomena: None reported.

Other perceptual disturbances: None observed.

IMPRESSION: perception intact

COGNITIVE FUNCTIONS

Attention:

 Arousal: Normally aroused.

 Digit forward: The patient was able to repeat 5 digits forward correctly.

 Digit backward: The patient was able to repeat 4 digits backward correctly.
Concentration:

 Sustained: Normally sustained but with some difficulty due to distractibility.

 100 – 7 test:

o 100 – 7 = 93 (correct)

o 93 – 7 = 86 (correct)

o 86 – 7 = 79 (correct)

o 79 – 7 = 72 (correct)

o 72 – 7 = 65 (correct)

 40 – 3 test:

o 40 – 3 = 37 (correct)

o 37 – 3 = 34 (correct)

o 34 – 3 = 31 (correct)

o 31 – 3 = 28 (correct)

o 28 – 3 = 25 (correct)

 20 – 1 test:

o 20 – 1 = 19 (correct)

o 19 – 1 = 18 (correct)

o 18 – 1 = 17 (correct)
 o 17 – 1 = 16 (correct)

o 16 – 1 = 15 (correct)

 Names of months (backwards): The patient was able to name the months backwards

with some hesitation but completed the task correctly.

 Names of weekdays (backwards): The patient was able to name the weekdays

backwards with some hesitation but completed the task correctly.

IMPRESSION: attention and concentration are intact

ORIENTATION

Time: Fully oriented (correctly identified the date, day, month, and year).

Place: Fully oriented (correctly identified the hospital and city).

Person: Fully oriented (correctly identified herself, family members, and hospital staff).

IMPRESSION: orientation to time, place, and person intact

MEMORY

Immediate memory: Intact (digit forward and backward tests).

Recent memory:

 Recent happenings: The patient was able to recall her last meal and the fact that she was

brought to the hospital by her husband.

 Verbal recall:
 o After 5 minutes: The patient was able to recall 3 out of 5 unrelated objects (e.g.,

apple, table, river).

o After 10 minutes: The patient was able to recall 2 out of 5 unrelated objects.

 Visual recall: The patient was shown 3 unrelated objects (e.g., pen, book, chair) and was

able to recall 2 out of 3 after 5 minutes and 1 out of 3 after 10 minutes.

Remote memory: Intact. The patient was able to recall significant personal and

impersonal events.

IMPRESSION: memory intact

INTELLIGENCE

Comprehension:

 Simple commands: The patient was able to follow simple commands (e.g., "Close your

eyes," "Raise your hand").

 Complex commands: The patient had difficulty following complex commands (e.g.,

"Take this paper in your left hand, fold it in half, and place it on the table").

Vocabulary:

 Common objects: The patient was able to name common objects (e.g., pen, chair, book)

without difficulty.

 Uncommon objects: The patient struggled to name uncommon objects (e.g., stethoscope,

microscope).
  Parts of objects: The patient was able to identify parts of objects (e.g., "What is the part

of a chair you sit on?" Answer: "Seat").

Arithmetic ability:

 Mental arithmetic: The patient was able to perform simple calculations (e.g., 5 + 7 = 12)

but struggled with more complex problems (e.g., 23 – 8 = 15).

General fund of information:

 Literate: The patient is literate and has completed high school.

o Name of the Prime Minister: The patient was able to name the current Prime

Minister correctly.

o 5 rivers, cities, or states: The patient was able to name 5 rivers (e.g., Ganga,

Yamuna, Brahmaputra, Godavari, Krishna) and 5 cities (e.g., Delhi, Mumbai,

Chennai, Kolkata, Kochi).

o Capitals of countries: The patient was able to name the capitals of a few

countries (e.g., India – New Delhi, USA – Washington D.C., UK – London).

o Current events (Major): The patient was able to recall some major current

events (e.g., recent elections, natural disasters).

IMPRESSION: intelligence average

ABSTRACTION

Abstraction: Concrete.

Interpretation of proverbs:
  Proverb: "People who live in glass houses shouldn’t throw stones."

o Patient’s interpretation: "If you live in a glass house, stones will break it."

(Concrete interpretation, no abstract understanding.)

 Proverb: "A stitch in time saves nine."

o Patient’s interpretation: "If you sew something, it won’t tear." (Concrete

interpretation, no abstract understanding.)

Similarities between paired objects:

 Example: "How are an apple and an orange alike?"

o Patient’s response: "Both are fruits." (Correct but concrete.)

 Example: "How are a book and a movie alike?"

o Patient’s response: "Both have stories." (Correct but concrete.)

Dissimilarities between paired objects:

 Example: "How are a car and a bicycle different?"

o Patient’s response: "A car has an engine, and a bicycle doesn’t." (Correct but

concrete.)

 Example: "How are a river and a lake different?"

o Patient’s response: "A river flows, and a lake doesn’t." (Correct but concrete.)

IMPRESSION: abstraction is concrete

JUDGMENT
Judgment: Impaired.

 Personal: Poor sense of personal capability and worth. No clear plans for the future.

 Social: Impaired sense of socially and culturally acceptable behavior (e.g., suicidal

thoughts).

 Test: When asked how she would respond to an imaginary situation (e.g., "What would

you do if you found a stamped, addressed envelope on the street?"), the patient

responded, "I would throw it away because I don’t care about anything anymore."

(Impaired judgment.)

IMPRESSION: judgement not intact

Insight

 Awareness of Abnormal Behavior/Experience: Yes.

 Attribution to Physical Causes: No.

 Recognition of Personal Responsibility: Yes.

 Willingness to Take Treatment: Yes.

 Grade: 5 (Intellectual insight: Aware of being ill and that symptoms are due to irrational

thoughts, but struggles to apply this to current experiences).

DIAGNOSTIC FORMULATION

 Major Diagnosis: Major Depressive Disorder, Moderate-Severe (ICD-10: F32.2).

 Differential Diagnosis:
 o Adjustment Disorder with Depressed Mood.

o Persistent Depressive Disorder.

PSYCHOTHERAPY AND MANAGEMENT

1. Pharmacotherapy:

o SSRIs (e.g., Sertraline): First-line treatment for depression.

o Benzodiazepines (e.g., Clonazepam): Short-term use for anxiety and sleep

disturbances.

2. Psychotherapy:

o Cognitive Behavioral Therapy (CBT): To address negative thought patterns and

improve coping skills.

o Supportive Therapy: To provide emotional support and validation.

3. Lifestyle Modifications:

o Encourage regular exercise, balanced diet, and adequate sleep.

o Address work-life balance and stress management.

4. Family Psychoeducation:

o Educate family members about depression and involve them in the treatment

process.
PROGNOSIS

 Good Prognostic Factors: High motivation for treatment, supportive family, and no

comorbid psychiatric or medical conditions.

 Potential Challenges: Chronicity of symptoms (9 months) and impaired judgment may

require longer-term intervention.

CONCLUSION

Mrs. S presents with symptoms consistent with Major Depressive Disorder, characterized by

persistent sadness, loss of interest, fatigue, sleep disturbances, and suicidal thoughts. A

combination of pharmacotherapy (SSRIs) and psychotherapy (CBT) is recommended, along with

lifestyle modifications and family involvement. With appropriate treatment, her prognosis is

favorable.