CASE RECORD

APRIL 2013 SESSION

CERTIFICATE

This is to certify that this work titled CASE RECORD submitted by

Dr. M.KAVITHA ,as a part of fulfilment of the requirements for the
Diploma in Psychological Medicine course of The Tamil Nadu Dr.

M.G.R Medical University is an original and bonafide work.

Unit Chief :

Department of Psychiatry
Institute of mental health
Kilpauk

Professor & Head :

Department of Psychiatry
Institute of mental health
Kilpauk

The Dean :

Madras Medical College

Chennai 600003

ACKNOWLEDGEMENT

I sincerely thank Dr.V.Kanagasabai M.D, Dean, Madras Medical

College for his support and encouragement to help me complete this
case record as a part of completion of Diploma in Psychological
Medicine course.

I am deeply indebted to thank Prof. Dr.R. Jayaprakash, M.D., D.P.M

Director of Institute of Mental Health, Kilpauk for his never ending
support and guidance in completion of this case record.

I am grateful to Prof. Dr .V.S.KRISHNAN, M.D, Unit II chief, for being

a source of motivation and inspiration.

I also thank Department of Psychology, I.M.H for their valuable

reports which guided us in the treatment of all the patients.

Finally I would like to extend my gratitude to the patients and their

family members who cooperated for history taking.

Sl.

Name

Age

Sex

Diagnosis

No
1

Mr. C

34

Paranoid Schizophrenia

Mr. S

30

Mental and behavioral disorders due to

multiple drug use and use of other
psychoactive substances

Mrs. V

22

Complex partial seizures with obsessive

Master.S 10

compulsive disorder.
Mental Retardation - Moderate

Mrs. J

Dementia

71

CASE 1
IDENTIFICATION DATA OF THE PATIENT:

Page No.

Name

Mr.C

Age

34 yrs

Sex

male

Marital status

unmarried,

Education

B.Sc chem., GNIIT, MCA discontinued,

Occupation

worked in Tata tele services, modfurn, school and

not working for 1 year,

Language

: Tamil

Religion

Residence

Thiruvottriyur

Socio-economic status

MSES.

Informant

patient &Mother

Information

: Reliable, consistent and Adequate.

Hinduism,

VI th psychiatric consultation,

REASONS FOR CONSULTATION :

Aggressive and assaultive behavior
Suspiciousness
Sleep disturbances, excessive talk
Hearing

12 years

voices

5 years -

months
Onset Chronic
Course - continuous, deteriorating
Psycho social stressor :

Love failure

VI th psychiatric consultation,

increased for

REASONS FOR CONSULTATION :

Aggressive and assaultive behavior
Suspiciousness
Sleep disturbances, excessive talk

12 years

Hearing

5 years

voices

Onset Chronic
Psycho social stressor :

2 months

Course - continuous, deteriorating

Love failure

HISTORY OF PRESENTING ILLNESS :

Mr. C was apparently normal before 12 years. After completing BSc chemistry, he
joined GNIIT computer course in 1999. there he met a lady faculty, who was 14
years elder than him.[36-22]. He admired her as a good orator with kindness,
affection, good physique, good patience and good memory. He loved her but she
refused his proposal. She got married in Jan 2000.
He was much worried and claimed that she was in love with him and the
other faculty members and CIA [Central Investigation Agency] tried to harm him.
He also told that Mr. kulothunga cholan, a private detective agent was tried to kill
him. He was having aggressive and assaultive behaviours and assaulted his mom
in public. He had sleep disturbances with frequent awakenings.
He was taken to Psychiatric consultation at private hospitals and ECT
were given. He came to IMH in 2002 and He was admitted thrice
[2003,2004,20011] and treated withT. Haloperidol, T. Quetiapine,T.
carbamazepine,T. chlorpromazine, T. Benzhexol. In between admissions, his
aggressive and assaultive behaviour decreased, but he continued to say that, she
was in love with him and cholan tried to kill him. On and off , he was going for
job for 4months &6months. He was on medication for the past 12 years. On and

off, he stopped medication for 1 week or 10 days and if the complaints reappears,
he used to continue the medications.
From 2006 onwards , he is having the complaints of hearing voices
of lover girl , CIA and cholan. He told that , he has been mesmerized by lover
girl, cholan telling him that ,he will be killed at the age of 43 years in 2020.
Patient is claiming that, cholan was appointed by CIA, as a middle
man to take blue films and cholan wants him to be the blue film hero. According
to the patient, blue film heroes will never exist on earth. They will be killed
after taking blue film. He claimed that , cholan is a pimp and he threatened
patients mom , that her son will be killed. To prevent that,she has to help him to
take bluefilms. She accepted for that and getting money [100 crores] from cholan
and taking blue film of neighbourhood husband and wives without their
knowledge.
He told that, his mom gave money to lover girl and other faculty
members to show body language to her son and be friendly with him. He claims
that , those girls are doing lesbian things and they are characterless. He told that ,
cholan, lover girl and himself were brought up by CIA. CIA wants him to be the
next don , so that he can control all politicians, threw them from power and the
lover girl will come to the power. He said that all world leaders are against him.
Patient said that , the lover girl was married in 2000 and CIA took her
to USA as a dead body and there , she got her life again and lived with his father.
Father was killed in 2008, by cutting in to 4 pieces by that girl. But , according to
mothers statement, father died in December 2005 due to cerebro vascular
accident.

From 2006, he can hear voices of lover , telling him that, his activities
are being controlled and recorded by brain scanners and ear pieces kept by CIA
,which could not be detected even by a CT scan. He knew this by others body
language and pitching. He gave explanation for the word pitching as
diplomatic way of getting information. They are controlling him like a Robot.
He told that CIA will make him a top hero and I.K.Gujral and
Chandrasekhar have became prime ministers ,jus because of him. He told that,
Former US president visited India in 2000 to meet Chandra babu Naidu, but
actually, Chandra denotes patients name and visit was to meet him only. He also
claims that all the men in the block [co-patients] and doctors are middle men of
CIA. After seeing a bike number during the interview, he said that the number is
S8111. here 8 denotes 8 years and 1 1 1 denotes his father , his mother, and
himself. So after 8 years, at his 43 yrs, three of them will be killed by cholan.
He had sleep disturbances,with frequent awakenings and unable to sleep properly.
2 months ago, he stopped all medicines and took native medicine. Then he
became too aggressive and started to assault his mom in public places and he was
admitted in IMH.
No H/o head injury/nasal bleed /fever preceeding illness
No H/o bladder and bowel disturbance/loss of consciousness
No H/o seizures/ suicide/ repetitive acts
No H/ o thought broadcast/thought withdrawal/thought insertion
PAST HISTORY : In 1998, he underwent knee patellar surgery after a RTA
injury. In 1999, he suffered from typhoid and took treatment .
No H/o diabetes/ Hypertension/ Ischemic Heart Disease
No h/o bronchial asthma/ tuberculosis

No previous Psychiatric illness.

FAMILY HISTORY :
1st born from Non consanguineous marriage.
No H/o. Alcohol dependency in family.
No h/o. Epilepsy / mental retardation
No h/o. Substance abuse in the family.
No h/o. Suicidal death in the family.
PAST PERSONAL HISTORY :
Early childhood

FTNVD at hospital
Devolopmental milestones are normal

Middle childhood

Went to school at 5 years of age .

Good scholastic performance,

Late childhood

He participated in chess tournaments and quiz

programme
Occupational History :

worked in Tata tele services, modfurn, school and

not working for 1 year,

Marital history

Unarried.

Habits

Smoking on and off

Sexual history

No H/o premarital contacts.

H/o masturbation once in a week.

Legal History

Nil significant

PREMORBID PERSONALITY :
Friendly, Extrovert, jovial, communicative, stable , responsible and helping
tendency. No deviant traits.
PHYSICAL EXAMINATION :
Alert,afebrile

BP ; 100/70 mmHg
PR : 82/min
CVS

: S1 S2+ NAD

RS

: NVBS , NAD

P/A

: Soft, No Organomegaly

CNS

: No FND. Fundus Normal

MENTAL STATUS EXAMINATION :

General appearance, Behaviour, Attitude: Moderately built, alert, ambulant,
clean, kempt, dressed adequately, co-operative, rapport established with
difficulty, gaze contact made
Motor Activity : Normal
Speech : Spontaneous excessive talk, relevant Quantum, Rate ,Tone- Increased,
Reaction Time-Normal
Mood : fearful

[scared of being killed by somebody]

Affect : suspicious, broad, appropriate, No lability

Thought: form Normal, Stream- Increased ,
Content Delusion of Control,
[he can hear voices of lover , telling him that, his activities are being controlled
and recorded by brain scanners and ear pieces kept by CIA ,which could not be
detected even by a CT scan]
-Delusion of reference,
[He claims that all the men in the block [co-patients] and doctors are middle men
of CIA]
-Delusion of persecution

10

[He told that Mr. kulothunga cholan, a private detective agent was tried to kill
him]
-Ideas of grandiosity,
[He told that CIA will make him a top hero and I.K.Gujral and Chandrasekhar
have became prime ministers ,jus because of him]
Perception: Auditory Hallucination present
Attention and Concentration: Intact
Oriented to time , place, person.
Memory

: intact

Intelligence: Average
Judgment: Social- impaired, Hypothetical- intact
Insight

: Absent.

Investigations: Routine blood investigations Normal

CT Brain, EEG

-Normal

PSYCHOLOGICAL ASSESSMENT :
TEST ADMINISTERED:
1. Symptom Sign Inventory
2. Eyesencks Personality Questionnaire
3. Sentence Completion Test
4. Thematic Appreception Test
5. Rorschach Psycho diagnostic Test
6. Positive and Negative Syndrome Scale (PANSS)
7. Hamilton rating Scale for Depression
8.Bender Gestalt test

11

On Scales for the Assessment of Positive Symptoms (SAPS) ,global rating for
hallucinations showed marked with auditory hallucinations of voices commenting
nature. For delusions, patient obtains severe global rating with persecutory
delusions, grandiose ideations, delusions of reference, delusion of being
controlled. And delusions are of systematized in nature.

On Positive and Negative Syndrome Scale (PANSS) patient obtained a score of

28 on positive symptoms, 6 on negative and 38 on general psychopathology.
Composite index showed prominent positive symptoms and , thought disturbance
and paranoid are significant.
On Rorschach test patient gave 14 total responses with delayed mention time.
Patient has given3 popular responses , 11 originals with negative form level
rating. Content analysis showed animals geographical maps, sexual responses and
bizarre nature. Patient was able to perceive popular responses in testing of limiys.
On Global Assessment Functioning, patient obtains a rating 40 -31, indicating
some impairment in reality testing major impairment in work, family relations,
judgment and thinking.
Impression was patient with adequate cognitive functions with evidence of
psychotic illness of Paranoid Schizophrenia.

DIAGNOSTIC FORMULATION

: A 34 yr old unmarried, educated male

is brought for the complaints of aggressive and assaultive behaviour,

suspiciousness, excessive talk, and sleep disturbances for 12 years, hearing
voices for 5 years and increased for 2 months, chronic, continuous, and
deteriorating with psycho social stressor of love failure, poor response to

12

treatment for 12 years, MSE : Rapport established with difficulty , gaze

contact made, Motor activity normal, Speech- Quantum, Tone, Rate-Increased,
Reaction time- Normal , Mood- fearful, Affect Broad,appropriate, No lability,
ThoughtForm-Normal, Stream-Increased, Content- Delusion of control,
Delusion of reference, Delusion of persecution and ideas of Grandiosity.
Perception Auditory hallucinations present., Judgment-Impaired, Insight- Absent
.
DIAGNOSIS:
F.20. SCHIZOPHRENIA
F 20.0

PARANOID SCHIZOPHRENIA.

MANAGEMENT:
PHARMACOTHERAPY :
T.Olanzapine 5mg

1-0-1

T.Haloperidol 5mg

1-0-3

T.Benzhexol 2mg

1-1-1

T.Risperidone 2mg

3-0-3

T.Sodium Valproate 200mg

2-2-2

C.Fluoxetine 20 mg

1-0-0

T.Diazepam 5mg

0-0-2

PSYCHOTHERAPY :
Family education about his illness, symptoms, course of the illness and
need for continuous treatment.
Cognitive Behaviour Therapy to be given after the control of symptoms.
Improving coping skills training to be given.

13

Interpersonal and social rhythm therapy to reduce the lability of mood to

maintain regular pattern of daily activities.

CASE 2

14

IDENTIFICATION DATA OF THE PATIENT:

Name

Mr. S

Age

30 yrs

Sex

male

Marital status

married,

Education

Language

: Tamil

Religion

: following Hinduism,

Residence

: Ambattur

Socio-economic status

MSES.

Informant

patient & Mother

Information

: Reliable,consistent and Adequate.

+2

REASONS FOR CONSULTATION :

Alcohol consumption 10 yrs, Increased daily consumption 2 months
Sadness - 5 months
Cocaine consumption
Sleep disturbances
Loss of appetite
4 months
Loss of weight
Cannabis consumption
Hearing voices
2 months
Suicidal thoughts
Onset sub acute
Course - continuous, progressive
Psycho social stressor: separation from spouse
HISTORY OF PRESENTING ILLNESS :
Mr. S had first drink of alcohol, 10 yrs back in the company of friends. He used to
consumed beer occasionally and he started smoking [5-10 cigarettes per day].

15

After Tsunami ,2004,he suffered loss in seafood business and his frequency of
alcohol consumption increased to twice or thrice weekly about 180ml of alcohol.
He was working in a gym as an instructor. He met a lady there and
was in affair with her for 8 months.during this time, he remained abstinent from
alcohol. He went to Bangalore and married her at a temple with her family
members alone on December, 2011. he lived with her for 2 weeks. During that
time, he was ill treated by her parentsand he was much worried and felt very sad.
For this, he sought the help of a tamil friend there, and he
introduced him to cocaine and gave him Intravenous pentothal injection for 3
consecutive days. He took a small room for rent and stayed there alone. Initially,
he was provided cocaine at free of cost. But later, when patient started repeatedly
asking him for more cocaine, he told him the place, where it was sold. From then
on , he used to go to that place and buy 10mg of cocaine for 2300 rupees. He
pledged his gold chains and golden bracelet to obtain money for cocaine.
He used to consume cocaine by sniffing. Following intake, he
used to feel high, as though he was holding the moon in his hand. He said that the
high he felt is more pleasurable than sexual pleasure. He said that , whenever he
used to listen to music ,while under the influence of cocaine, he can see it
colourfully.[seeing audio as video].
At that time, he was able to see objects and people as though,
they were reduced in size, as toys and those little people were walking over his
hands. He felt as though ants were crawling under the skin when he was under the
influence of cocaine..
He used to consume cocaine throughout the day even up to 10-15 pockets
per day. His food intake reduced and lost his weight from 110kg to 60kg. he found
it difficult to fall asleep at night. He spent all the money he had and he was
unable to buy cocaine.

16

He borrowed money from his friend and came to Chennai.

While going home by auto, he asked the driver for some addictive drug, he has
been given cannabis in the form of cigarette. He started to consume alcohol and
cannabis daily starting early in the morning, as he was not having enough money
to buy cocaine.
His sleep disturbances continued and he used to feel very tired
and he lost interest in communicating with others and he never tried to contact his
wife again. He feels that his family members are not giving importance to him and
he feels very low. He had intense desire to consume cocaine. At times, he heard
the voices of unknown female, which used to command him to die and the voice
used to tell him. That he was useless and worthless. During those period , he
attempted suicide on two different occasions, by hanging in the fan with the saree.
On both the occasions, he attempted on impulse, he had locked the door of his
room from inside and family members had broken in to room immediately and
aborted the attempts.
He was brought to IMH, on may 2012 and the treatment was
started.
No H/o head injury/nasal bleed /fever preceeding illness
No H/o bladder and bowel disturbance
No H/o seizures/ elated mood/talking to self/ laughing to self
No H/ o thought broadcast/thought withdrawal/thought insertion
PAST HISTORY :
No H/o diabetes/ Hypertension/ Ischemic Heart Disease
No h/o bronchial asthma/ tuberculosis / surgery in the past
No previous Psychiatric illness.

17

FAMILY HISTORY :
1st born of Non consanguineous marriage.
H/o. Alcohol dependency in his father.
No h/o. Epilepsy / mental retardation
No h/o. Substance abuse in the family.
No h/o. Suicidal death in the family.
PAST PERSONAL HISTORY :
Early childhood

FTNVD at hospital
Devolopmental milestones are normal

Middle childhood :

Went to school at 5 years of age .

Average scholastic performance, studied upto +2 standard

Late childhood

He was not very responsible.Not regular to work.

He has many friends

Marital history

Married. History suggestive of marital conflicts

Habits

As described above.

Sexual history

No H/o premarital and extra marital contacts

Legal History

Nil significant

PREMORBID PERSONALITY :
Extroverted,outgoing,short tempered , not responsible or caring towards the
family.Has many friends
Boastful in nature,not adjustable with others.
PHYSICAL EXAMINATION :
Alert,afebrile
BP ; 100/70 mmHg
PR : 82/min
CVS

: S1 S2+ NAD

18

RS

: NVBS , NAD

P/A

: Soft, No Organomegaly

CNS

: No FND. Fundus Normal

MENTAL STATUS EXAMINATION:

General appearance, Behavior, Attitude: , Moderately built,dressed
appropriately, clean,kempt, no gaze avoidance, co-operative, rapport established
Psycho Motor Activity : Within Normal limits.
Speech : Quantum, Rate, Tone- Normal, Reaction Time-Normal
Mood : Depressed
Affect : Broad, appropriate, No lability
Thought : No Formal thought disturbance , Content craving for cocaine and
alcohol, suicidal thoughts present, low self esteem, ideas of hopelessness
Perception : Auditory Hallucination + commanding
Attention : Intact
Oriented to time , place, person.
Memory

: Immediate, Recent,Remote - Intact

Intelligence :

Average

Judgment : Social & Hypothetical- impaired

Insight

: Present

INVESTIGATIONS : Routine blood investigations Normal

CT Brain - Normal.
EEG

- Normal study

PSYCHOLOGICAL ASSESSMENT :
Eysenck Personality Questionnaire He is found to be an ambivert person, got
high scores on lie scale, may be due to manipulative and attention seeking
suggestive of inadequate personality
On International Personality Disorder Examination [screening tool], he got
significant scores on Impulsive Personality Disorder.

19

MultiPhasic Questionnaire and Symptom Sign Inventory, showed significant

scores on Depression.
On HAM-D , he got mild to moderate level of depressive features like suicidal
attempt , insomnia,feeling of worthlessness, unable to concentrate and not
interested in work .
Rorschach Inkblot Test showed he has below average productivity with
adequate mentation.
On Addiction Severity Index he got significant scores in the area of alcohol and
drug dependence
DIAGNOSTIC FORMULATION

: A 30 yr old married male with the

complaints of alcohol, cocaine, cannabis consumption , sadness , sleep

disturbances, loss of appetite and weight , hearing voices, suicidal thoughts ,
with family h/o alcohol abuse in father, separated from spouse with MSE
findings , Mood- depressed, Affect reactive ,appropriate, ThoughtNo
formal thought disturbance ,Content- craving for cocaine and alcohol, suicidal
thoughts, low self esteem, ideas of hopelessness, Perception Auditory
hallucinations present., Judgment-Intact, Insight- present .
DIAGNOSIS:
1.

F19 Mental and behavioral disorders due to multiple drug use and use of
other psychoactive substances
F19.2 Dependence syndrome
F19.5 Psychotic disorder
F19.54 Predominantly depressive symptoms

2. F32 Depressive Episode

F32.3 Severe depressive episode with psychotic symptoms

PHARMACOTHERAPY :
20

1.
2.
3.
4.

T. Carbamazepine 200mg 1-0-1

T. Sertraline 50mg 1-0-0
T. Haloperidol 1.5mg 1-0-1
T.Chlordiazepoxide 10 mg 2-2-4

PSYCHOTHERAPY :
He was given group therapy for prevention of cannabis use in the future and
educated about the risk of failure of treatment on continuing cannabis. .His family
was educated about the importance of family support in the recovery of the
patient.

CASE 3

IDENTIFICATION DATA OF THE PATIENT:

Name

Mrs. V

Age

22 yrs

Sex

female

21

Marital status

Education

Language

: Tamil and kannada speaking

Religion

: following Hinduism,

Residence

married,
Xth discontinued

: hailing from Salem

Socio-economic status : LSES.

Informant

: Father and Mother

Information

: Reliable,consistent and Adequate.

REASONS FOR CONSULTATION :

Fits

..

Repetitive acts
Excessive hostility towards parents

4 years

Setting fire
Anger outbursts

2 years

Poor self care

Onset Chronic

8 months

Course - continuous,

No Psycho social stressor

HISTORY OF PRESENTING ILLNESS :

22

13 years

Mrs. V had an episode of fits at her 9 years of age, which was charecterized by
periods of unresponsiveness associated with lip smacking, blinking, picking up
clothes suggestive of automatism which was followed by hand wringing. Each
episode lasts for 30 se-to 1min and this was followed by a period of confusion for
about 10 minutes. The episodes are not associated with tongue bite, vomiting,
froathing in mouth, passing urine or stools in dressand any other external injuries.
It used to occur once or twice in a month. Parents noticed that ,she was also slow
in her day to day activities, poor scholastic performance at school.she was taken
to neurologist and treatment was given.[T.gardinal, T.Levetiracetam]
Four years ago she was noticed to be washing her hands frequently, more than 15
times per day and she was taking long hours to take bath [nearly 1-2 hrs] . Even
on touching phones, cell phones &TV remote controls, she used to wash her hands
with soap. She asked her parents to stand in aplace and to command them to
move some steps away from her and then again asked them to come nearer to her
repeatedly for 2-3times.she also rotate her hands over the parents hand , if they
had touched it. when she was questioned for that, she repliedthat, they will not
leave her alone ,if she did these acts.she used to lift bags up and keep them down
again and again frequently and walk few steps to and fro in the stairs repeatedly.
She used to collect God and Goddess images from newspapers and sweet covers.
She expressed that ,it was not necessary to do all these acts, but she cant control
herself to prevent from these acts . she feels that, she is not like others by doing
this and she wants to stop all these repetitive acts.
She was taken to private psychiatrist and was treated as an inpatient for 2 months
in oct, nov of 2009. MRI Brain was done & it showed Right medial temporal
sclerosis and She was started on T. oxcarbazepine 300mg 1-0-2,

23

T.

levetiracetam 500mg 1-0-1, T.Clobazem 10mg 0-0-2,,T.Quetiapine 50mg 1-2-3,

T.Escitalopram 20mg 0-0-1.
She improved with medication, but stopped on her own due to excessive
drowsiness. She showed excessive hostility towards parents and blaming them for
every thing. She started to cut her parents clothes, plastic chairs and burn them
with candles.wnenever she was questioned, she used to get irritated and go out of
home to nearby temples or bus stand and would return on her own after 2-3hrs.
she wanted to get married as both the parents are nagging always.
She got married on last year and she completely stopped all medications. In
husbands home, she was not interacting with others freely, not helping her
mother-in-law in house hold works. She is maintaing poor relationship with
husband and she was brought to her mothers home by her husband and left there.
For the past 8 months, she is staying with her parents and showing irritability,
stubbornness, maintaining poor self care.durin all these period, she is having
seizure episodes once in amonth[with drugs]. And twice a week [without drugs]
No H/o head injury/nasal bleed /fever preceeding illness
No H/o bladder and bowel disturbance
No H/o loss of weight/ loss of appetite/ crying spells
No H/o suicidal ideations/ elated mood/talking to self/ laughing to self
No H/ o thought broadcast/thought withdrawal/thought insertion

PAST HISTORY :
An episode of febrile fits at the age of 3 years and treated in local hospital.
No h/o bronchial asthma/ tuberculosis / surgery in the past
FAMILY HISTORY :

24

2nd born from Non consanguineous marriage. No family

history of similar illness.
PAST PERSONAL HISTORY :
Early childhood

FTNVD at hospital
Devolopmental milestones are normal

Middle childhood :

Went to school at 5 years of age .

Poor scholastic performance, studied upto VI th

standard in English medium.

H/o enuresis till 10 yrs of age.

Late childhood

she studied in tamil medium since VIIth std.

discontinued in Xth std as she was not able to cope up,

Menstrual History

Attained menarche at the age of 13 yrs. RMP,

LMP- 20 days ago
Nil Gynaecological problem.

Marital History

Married at the age of 21 yrs. Features suggestive of

Sexual History

No H/o premarital and extra marital contacts.

Habits

watching TV

Legal History

Nil significant

marital conflicts

PERSONALITY

Introvert, Not communicative, stubborn, shy, No h/o

excessive cleanliness and orderliness, No deviant traits

PHYSICAL EXAMINATION :

25

Alert,afebrile
BP ; 100/70 mmHg
PR : 82/min
CVS

: S1 S2+ NAD

RS

: NVBS , NAD

P/A

: Soft

CNS

: No FND. Fundus - Normal

Head Circumference - 54 cms

Secondary sexual characters are fully developed.No Neurocutaneous markers, No
external anomalies.

MENTAL STATUS EXAMINATION :

General appearance, Behavior, Attitude: Moderately built, alert, ambulant,
untidy,unkempt, dressed adequately, not co-operative, rapport established with
difficulty, gaze avoidance, guarded and evasive, not interested in interview,
vacant stare look for most of the time.
Motor Activity : Normal, increased at times.
Speech : no spontaneous talk, relevant and coherent,Rate,Tone- decreased,
Reaction time-Prolonged
Mood : dysthymic
Affect : sad,restricted, appropriate, No lability
Thought : form Normal,Stream- decreased thought output , Content No
depressive thoughts, Possession- obsession ; repetitive thoughts and performing
irrational, repetitive acts. Magical thinking+.[ believes something will go wrong
if she does not move about in a specific pattern]

26

Perception : no disturbance
Attention : Intact
Oriented to time , place, person.
Memory

: Immediate, Recent,Remote - Intact

Intelligence : Below Average

Judgment : Social- impaired , Hypothetical- impaired
Insight

: Present .

INVESTIGATIONS Routine blood investigations Normal

MRI Brain
EEG

Right medial temporal lobe sclerosis

-Normal

PSYCHOLOGICAL ASSESSMENT :
Eysenck Personality Questionnaire showed she has an ambivert type of
personality with significant neurotic tendencies. Her lie scale score is non
significant.
Middlesex Health Questionnaire she had significantly high scores on all
dimensions showing high neuroticism. She was not responding to Rorschach
cards.
Y-BOCS, HAM-D showed that she has severe level of depression [HAM-D-24]
and symptoms of obsessions and compulsions

DIAGNOSTIC FORMULATION : A 22 yr old married female is brought

for the complaints of Fits for

13 years, Repetitive acts and Excessive hatred

towards parents -4 years,Setting fire and Anger outbursts- 2 years,Poor self care

27

 8 months MSE : Rapport established with difficulty , gazeavoidance, guarded

and evasive, not interested in interview,vacant stare look for most of the time ,
Motor activity normal, Speech- no spontaneous talk, relevant and
coherent,Rate,Tone- decreased, Reaction time-Prolonged , Mood- dysthymic,
Affect sad, restricted,appropriate, No lability, ThoughtForm-Normal, Streamdecreased thought output, Content No depressive thoughts, Possessionobsession repetitive thoughts :performing irrational, repetitive acts ,Perception
no disturbance , Attention intact, oriented to time ,place and person, Memoryintact, Intelligence- Below average, Judgment-Impaired, Insight- Pressent .

DIAGNOSIS:
According to ICD 10,

F 06.8 Other specified mental disorders due to brain damage and dysfunction
and to physical disease
F 42 -

Obsessive- Compulsive disorder

42. 1

3.

F 70

Predominantly compulsive acts

[obsessional rituals]

- Mild Mental retardation

70.1 - significant impairment of behaviour requiring attention or

treatment.

According to DSM IV TR,

Axis I

- 300.3 Obsessive Compulsive Disorder

Axis II

- 317

Mild Mental Retardation

28

Axis III

- Complex Partial Seizures

Axis IV

- High Expressed Emotion in the family- ?Marital disharmony

Axis V

- GAF [ 50 41 ]

MANAGEMENT :
PHARMACOTHERAPY:
T. Carbamazepine 200mg 1-1-1
C.Fluoxetine 20mg

1-0-0

T. Diazepam

0-0-1

PSYCHOTHERAPY :
Cognitive Behavior Therapy To manage his irrational beliefs and to modify the
subsequent unwanted behaviour. Focuses on the obsessions.
Exposure Response Prevention To manage the compulsions
Thought stopping

- To control the obsessive thoughts

Family Education

- To manage Expressed emotion in the family

CASE 4

IDENTIFICATION DATA OF THE PATIENT:

Name

Master S

Age

: 10 yrs

29

Sex

: male child,

Marital status

Education

Language

: Tamil speaking,

Religion

: following Hinduism,

Residence

: hailing from Chennai

unmarried,
studying III rd std in special school

Socio-economic status : LSES.

Informant

: Father and Mother

Information

: Reliable,consistent and Adequate.

REASONS FOR CONSULTATION :

Delayed developmental milestone since birth

Self harming

4 years

Adamant behaviour

Increased for the past 4 months

Onset

- insidious,

Course

-Continuous , progressive

No obvious stress factor.

30

HISTORY OF PRESENTING ILLNESS

Master S ,10 years old male child second born for a 3rd degree consanguineous
parents with history of mother taking abortifacient in the form of two tablets for
three days at the 40th (1 month) of LMP, as she thought that her husband will
not be able to give proper (financial) care for that pregnancy. He already had not
given proper financial care for her even before the pregnancy.

Then she consulted gynaecologist for termination of pregnancy. She went

to the operation theatre as per the advice of the gynaecologist for D&C. As she
was being prepared in the theatre and when she saw the instruments, became
afraid and ran out the theatre then out of the hospital.

She went to her mothers home, the pregnancy continued uneventfully. She
delivered a male baby FTND in hospital without perinatal complications. After
the baby was delivered with deformed Right pinna as like that his maternal
Grand father. Cried soon after birth. Breast fed on the day of birth. Baby birth
weight 3.2 kgs.

As the child started growing parents started to notice delaying attainment of

developmental milestones as they compare to their first child. He significantly

31

noted a delaying attainments of language and adaptive behaviours. Attainments

of various developmental milestones as per the mothers history as follows

MOTOR BEHAVIOURS:

Moves head laterally in prone position was achieved at 2 months (4wks).

Momentarily lifts head when prone was attained at the 3months (4wks).
Head holdings: lift head to 90% when prone attained at the 5 months.

Sits with support attained at the 7months (5months).

Sits without support attained at 10 months (8months)
Stand with support attained at 11 months (9months)
Stand without support attained at 12 months (10months)
Walk well without support at 18 months (14-15months)
Run well, throw ball at 2years.

ADOPTIVE BEHAVIOURS:

Follows the moving objects, even away from the midline was attained at the
4months.
Grasps objects, transfer objects from hand to other was attained at 2years
(4-5months).
Claps hands was attained at 10 months.
Gives hand, held objects to mother was attained at 2 years (1year).
Makes a tower of 3-4 cubes was not attained up to 6 years.

32

LANGUAGE:

Turn head and responds to sound of a bell was attained at 6months (4wks).
Laugh loudly attained at 5months (3months).
Produce incomprehensible sounds ma, ba was attained at 12months
(9months)
Used 1-2 words meaningfully at the age of 6years (1- 1 years).
Two word utterance-8-9 years
Says Amma -6years.
Parts of the body identified at 6 years (2 years).
Colour naming attained at 7years after training (5 years).

He was able to telling his name when asked, that to after a special school
training.
PERSONAL AND SOCIAL BEHAVIOURS:
Social smile was attained at 5months (2-3 months).
Recognize mother was attained at 4months (3months).

Takes food to mouth was attained at 7months (6months).

Response to restricted social play was attained at 12months (9months).

Wear simple garments socks / shoes at 3 years (2years).

33

Unbutton to button was attained at 6 years (3 years).

Button the dress well was attained at 8 years (4years).

Dress without supervision was attained at 10years (5years).

Toilet training was attained at 8years (2years).

Parents noticed him to be very adamant as any other new relatives

including his grandparents visit his house or any other child tend to visit his
house, he used to push them out of the house in spite of their repeated warnings.

He demands switch on the TV continuously, in spite of him does not watch any
channel . If the TV was switched off, he started cry excessively till the TV has
been switched on. He used frequent quarrels with his elder sister even if she came
to speak with him, initiated play with him, within few minutes he used to beat her
continuously necessitating his parents to come and separate them. He would break
also frequently any things of her.Parents found that he was totally not obeying to
any of their commands even if he called for giving food, taking bath.
These behaviours occurs nearly 4-5 times/ day. All these behavioural

disturbances progress to next two years making him very unmanagable in home.

They took him to the dept.of child psychiatry at ICH Egmore where he was

34

treated with T.Chlorpromazine25mg 0 . Parents

were advised to join him in special school. On continuous treatment his parents

noticed slight improvement in behaviour and he was joined in a special school

in Porur.

Initial few days he would refuse to get dress for school. He would also

create problems like shouting, crying loudly in the train, while his mother taking

to school. Even in school sit himself alone looking in to the chair, doesnt

listening to any classes and frequently looking outside, even his teachers forces

him, he never listen to him.

These behavioural disturbances occur more frequently for the past 4months
15-20 time per days. He was brought for these complaints to IMH.

No h/o. Recurrent high fever

No h/o. Projectile vomiting
No h/o. Head injury with LOC
No h/o. Jaundice

35

No h/o. Unedible object eating.

PAST MEDICAL HISTORY:

No H/o Bronchial asthma/ Primary tuberculosis in the past
No H/o surgery in the past

FAMILY HISTORY:
2nd Born of 3rd degree consanguineous parent.
H/o. Seizure disorder in his paternal uncle.
H/o. Maternal uncle died at the age of 5years (?MR)
H/o. Suicidal death in his maternal grand father +
No h/o. Alcohol dependence / substance abuse.
No h/o. Congenital abnormalities in the family.

PHYSICAL EXAMINAaTION:
Alert , Afebrile
Ambulant
Height 136cms.
Head circumference 45cms.
Vitals stable.
No low set ears .
(R) ear pinna deformed.
No slanting of eyes.
Limbs and skin normal.
No hyper flexibility of joints.

36

CVS S1 ,S2 +
RS NVBS +
P/A Soft, no organomegaly.
Genitalia -normal
CNS : no FND
Motor :
Tone & bulk normal.
Reflexes normal.
No tics / tremor.
Spine and cranium normal.
No cerebellar signs.
No peripheral nerve thickness.
Gait normal.

TEMPERAMENT TRAITS

1. Activity level-95% of time spent in activity alone, restricted, stereotypy,

solitary activity.
2. Distractability more than 90% stimuli are allowed to alter behaviour.
3. Adaptability not able to move to changes.
4. Attention span predominant short attention span. Selectively able to
sustain attention

37

MENTAL STATUS EXAMINATION:

General Appearance, Attitude and Behaviour:
Dressed in clean, appropriately dressed. Takes seat without prompting but
doesnt remain seated. Does not look at the examiner, when interviewed. Interacts
with his parents alone and grabs all objects present on the table. But returs
them when prompted. Keeps biting his hands, wrist, tongue, bangs table, sings a
few words, makes noise often . Rapport not established

General Motor activity: Increased. No tics / tremor.

Speech :

Spontaneously recites few words /verses communication simple

words
which are relevant to simple questions. Poverty of talk.
Thought:
Form could not be tested.
Stream decreased.
Content poverty of content. Verbal stereotypy noted.
Affect no predominant affect. Range restricted. Inappropriate at times.
Perception : Could not be tested.
Cognitive functions :
Attention could be aroused but not sustained.
Memory, orientation, abstraction could not be tested.
Insight could not be assessed.

INVESTIGATIONS:

38

Routine blood investigation WNL.

MRI Brain normal study.
EEG Normal

PSYCHOLOGICAL ASSESSMENT :

Formal testing is not possible. However with possible testing her social
functioning is about 3 years as rated from Vineland Social Maturity Scale.
Seguine Form Board test showed marked impairment on relating to people.
Difficulty to follows instruction. Severe amount of abnormal listening responses.

There was impairment of verbal and nonverbal communication.

His intellectual responses also not consistant, which is not appropriate to his

age. Visuomotorfunction also impaired. His social age is lower than the mental

age. But mental age also not matching with his chronological age, at present his

mental age is 5 years. IQ will be around 48. But this IQ may not be reliable
comparing his scholastic skills, which his achieved through period of time by
special training.

DIAGNOSTIC FORMULATION:

39

Master S ,10 years old boy, studying 3rd std in special school, brought by his
parents with h/o. Delayed developmental milestones since birth and self harming
behaviour and adamant behaviour, Aggression towards others for the past 4
years, increased for the past 4months. Associated with a family h/o.
Seizure disorder in paternal uncle. ?MR in maternal uncle who died at 5years of
age and h/o. Suicidal death in maternal grand father. General systemic
examination WNL. MSE revealing a young boy dressed appropriately, not
interested in interview, with increased general motor activity associated with
frequently biting his hands, wrist, tongue, banging the table and singing few
words, making noises and with verbal stereotypy, communicating with few
single words relevant to questions also spontaneously reciting few words with
decreased stream of thought and poverty of content of thought, affect
inappropriate at times with aroused attention and ill sustained concentration
and patient not cooperative for further testing.

DIAGNOSIS:

F71 Moderate mental retardation

F71.1 Significant impairment of behaviour requiring attention or treatment

MANAGEMENT:
PHARMACOTHERAPY:

40

T.Haloperidol 1.5mg -0-

T.Benzhexol 2mg -0 -
T.Diazepam 5mg 0-0 -

PSYCHO THERAPY :
Behavior modification by shaping, prompting.
Rehabilitation and special school training.
Supportive family therapy. The importance of drug compliance has to be stressed

41

CASE 5 :

IDENTIFICATION DATA OF THE PATIENT:

Name

Mrs. J

Age

: 71 yrs

Sex

: female

Marital status

widow

Education

IVth std

Language

: Tamil speaking,

Religion

: following Hinduism,

Residence

: hailing from Chennai

Socio-economic status : LSES.

Informant

: son

Information

: Reliable, consistent and Adequate.

REASONS FOR CONSULTATION :

Forgetfulness in day to day chores - 3 yrs

Way finding difficulties

- 2 yrs

Irritable and abusive

Poor self care

Onset

- Insidious

Course

- Progressive

1 yr

42

HISTORY OF PRESENTING ILLNESS:

Mrs. J had difficulty in memorising day
to day needs. This was in contrast to her premorbid meticulous nature. During the
first year of life, she found it increasingly difficult to keep track of things,find
out things at home which were needed and go to the market to get groceries etc,.
she was quite distressed at times because of this. Far from her soft natured
behaviour, she sometimes went in to fits of rage over trivial matters and abused
her son and daughter-in-law. Her self care deteriorated over the last one year, as
she neglected the way she dressed, and her hair . she often walked out unkempt in
the neighbourhood. There was significant deterioration in her social relationships.
No H/o head injury/nasal bleed /fever preceeding illness
No H/o bladder and bowel disturbance
No H/o loss of weight/ loss of appetite/ crying spells
No H/o suicidal ideations/ elated mood/talking to self/ laughing to self

PAST MEDICAL HISTORY:

No H/o diabetes/ Hypertension/ Ischemic Heart Disease
No h/o bronchial asthma/ tuberculosis / surgery in the past
No previous Psychiatric illness.

FAMILY HISTORY:
3rd born of four siblings of 3rd degree consanguineous parents. Husband died 10
years ago. Her son looks after her now. No similar illness in the family.

43

PAST PERSONAL HISTORY:

Early childhood

FTNVD at hospital
Devolopmental milestones are normal

Middle childhood :

Went to school at 5 years of age .

Average scholastic performance, studied upto IV th

standard
due to family situation.
Late childhood

Menstrual History :

Helped her mother in household works

Attained menarche at the age of 13 yrs. RMP,
Attained menopause 21 yrs ago. Had 4 children.
Nil Gynaecological problem.

Marital history

Married at the age of 18 yrs. No marital conflicts

Sexual history

No H/o premarital and extra marital contacts

Legal History

Nil significant

PREMORBID PERSONALITY :
Meticulous, efficiently managed her house, good social relationships.
PHYSICAL EXAMINATION :
Alert,afebrile
BP ; 110/70 mmHg
PR : 78/min
Bilateral Mature cataract
CVS

: S1 S2+ NAD

RS

: NVBS , NAD

P/A

: Soft

44

CNS

: No FND

Lobar Functions are Normal

INVESTIGATIONS

CT Brain - Generalized atrophy of brain, enlarged lateral ventricles, prominent

sulci.
EEG

- Normal study

MENTAL STATUS EXAMINATION:

General Appearance, Attitude and Behaviour:

Conscious ,ambulant, alert, dressed
appropriately,unkempt, co-operative, rapport could be established with difficulty,
she appeared apathetic to the proceedings.
General Motor activity: Increased. Restless at times. No tics / tremor.
Speech :

relevant to simple questions.

Emotion :
Mood

- Euthymic

Affect

- apathetic affect. restricted. Inappropriate at times , No lability

Thought:
Form Normal
Stream - Normal
Content No delusions, No depressive thoughts.
Perception : No perceptual disturbances
Attention

: Impaired

Orientation :

DF -3, DB -2,

40-3, stops after 31

Not Oriented to time and place but oriented to person.

45

Memory

:
Immediate
Recent
Remote

Impaired
-

Intact

Intelligence :
Fund of information - Average
Abstract Thinking
Judgment

Insight

: Absent

- Poor

Social & Hypothetical - Impaired

PSYCHOLOGICAL ASSESSMENT:

Mini Mental State Examination She scored only 13 out of 30., showing
severe degree of cognitive impairment. There was disturbance in orientation,
registration and recall. She also had disturbance in language function. There is a
global cognitive impairment.
Bender Gestalt Test

- she was not able to copy the figure properly.

Her diagram had rotation, distortion and separation,that too after 2 or 3 attempts
which indicate disturbance in visuomotor gestalt functions.
Her recall was very poor as she could not recall a single drawing. She had
poor scores on verbal recall, and paired associate learning. Overall it points
towards moderate degree of impairment in her memory functions.
Behaviour rating scale

- shows altogether moderate change in

behaviour,. She shows exaggerated emotional reactions. She does not take interest

46

or initiate household activities. She has mild to moderate behaviour problems due
to dementia
Her Memory Quotient [MQ] assessed by Wechsler Memory Scale was
53, which is in poor range.
Dementia Rating Scale -

she had difficulty in performing her day to day

activities like coping with small sums of money, inability to find her way back,
difficulty in interpreting surroundings and recalling recent events. There were
changes in personality in the form of diminished emotional responsiveness and
diminished initiative and gross apathy on the whole suggestive of moderate to
severe degree of Dementia.

DIAGNOSTIC FORMULATION :
Mrs. J, 71 yrs old female, widow
studied up to IVth std with C/oForgetfulness in day to day chores - 3 yrs,Way
finding difficulties - 2 yrs, Irritable and abusive ,Poor self care for 1 yr
MSE showed . Motor activity: Increased. Restless at times Speech: relevant to
simple questions. Emotion : Mood

- Euthymic , Affect

- apathetic affect.

restricted. Inappropriate at times , No lability Attention :Impaired

Orientation : Not Oriented to time and place but oriented to person.
Memory: Immediate, Recent -Impaired, Remote -Intact
Intelligenc- Fund of information - Average ,Abstract Thinking - Poor
Judgment -Social & Hypothetical - Impaired ,Insight- Absent .

DIAGNOSIS:

47

F00 Dementia in Alzheimer's disease

F00.1Dementia in Alzheimer's disease with late onset

MANAGEMENT :

PHARMACOTHERAPY :
1. T. Donepezil 5mg

1-0-1.

2. T. Lorazepam 2mg

0-0-1

PSYCHOTHARAPY:
Family education : This is to give the family a realistic idea regarding the
illness and its prognosis. It also involves caring about a patient with dementia.
Dementia care : Essentially involves managing the patient and recognizing
the important areas which need special attention. The home environment should
be safe for the patient.

48

49