Case History Intro

INTRODUCTION
PRERANA HOSPITAL is a Multi-Specialty-Neuro Psychiatry, De-Addiction and

Rehabilitation center is run by Dr. H.S. Venkatesh (Chief Advisor) and Dr. H.R Abijith
(Director)
This Hospital was inaugurated on 9th June 2013 by Dr. H.S. Venkatesh (Chief Advisor) and
Dr. H.R Abijith (Director).
The De-Addiction center was started in the year 2013: it is a 50+ bedded hospital where more
than 35000 patients have already treated. The De-Addiction Center has a separate building
which has both general and special wards. The team comprises of dedicated mental health
professionals. Dr. H.S. Venkatesh well known psychiatrist in mysore region is leading the
team.
The Hospital offers the Following Services.
 Psychiatric Team comprising of psychiatrist clinical psychologists, Child guidance

counselors and occupation therapists.
 De-Addiction Center.
 Neuro Rehabilitation with Physiotherapist.
 Sexual health center.
 Headache clinic.
 Multi specialty consultation center with all major specialities.
 Major OT and ECT Suite.
 50+ bedded in – patient facility.
 Fully equipped Diagnostic center.
The psychology department of Prerana Hospital, De-Addiction and Rehabilitation center

deals with the following disorders.
 Alcoholism
 Substance abuse disorder
 Drug addiction.
 Schizophrenia.
 Paranoid Schizophrenia.
 Catatonia.
 Depression.
 Bipolar Affective Disorder.
 Acute and Transient Psychosis.
 Anxiety
 Personality disorders.
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Introduction
Psychotic disorders such as schizophrenia and mood disorders with psychotic features usually
manifest in young adulthood or middle age, and late-onset psychosis is comparatively rare.
However, some psychotic patients definitely present psychotic symptoms for the first time in
late life. Furthermore late-onset psychosis has different characteristics from those of the more
common early-onset psychosis.
As the population ages, the number of older persons with a major psychiatric disorder is
expected to increase. As a result late-onset psychosis will likely cause more serious problems
than before, and consequently research into this disorder is on the increase.
Usually the late on set psychosis person will have same symptoms and causes as psychosis
Psychosis is an abnormal condition of the mind that results in difficulties determining what is
real and what is not. Symptoms may include false beliefs (delusions) and seeing or hearing
things that others do not see or hear (hallucinations). Other symptoms may include incoherent
speech and behaviour that is inappropriate for the situation. There may also be sleep
problems, social withdrawal, lack of motivation, and difficulties carrying out daily activities.
Psychosis has many different causes. These include mental illness, such
as schizophrenia or bipolar disorder, sleep deprivation, some medical conditions,
certain medications, and drugs such as alcohol or cannabis. One type, known as postpartum
psychosis, can occur after giving birth. The neurotransmitter dopamine is believed to play a
role. Acute psychosis is considered primary if it results from a psychiatric condition and
secondary if it is caused by a medical condition. The diagnosis of a mental illness requires
excluding other potential causes. Testing may be done to check for central nervous
system diseases, toxins, or other health problems as a cause.
Treatment may include antipsychotic medication, counselling, and social support. Early
treatment appears to improve outcomes. Medications appear to have a moderate
effect. Outcomes depend on the underlying cause. In the United States about 3% of people
develop psychosis at some point in their lives. The condition has been described since at least
the 4th century BCE by Hippocrates and possibly as early as 1,500 BCE in the
Egyptian Ebers Papyrus.
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Symptoms
Symptoms of psychosis include:
 difficulty concentrating
 depressed mood
 sleeping too much or not enough
 anxiety
 suspiciousness
 withdrawal from family and friends
 delusions
 hallucinations
 disorganized speech, such as switching topics erratically
 depression
 suicidal thoughts or actions
Delusions and hallucinations are two very different symptoms that are both often experienced
by people with psychosis. Delusions and hallucinations seem real to the person who is
experiencing them.
Delusions
A delusion is a false belief or impression that is firmly held even though it’s contradicted by
reality and what is commonly considered true. There are delusions of paranoia, grandiose
delusions, and somatic delusions.
People who are experiencing a delusion of paranoia might think that they are being followed
when they aren’t or that secret messages are being sent to them. Someone with a grandiose
delusion will have an exaggerated sense of importance. Somatic delusion is when a person
believes they have a terminal illness, but in reality they’re healthy.
Hallucinations
A hallucination is a sensory perception in the absence of outside stimuli. That means seeing,
hearing, feeling, or smelling something that isn’t present. A person who is hallucinating
might see things that don’t exist or hear people talking when they’re alone.
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Causes of psychosis
Each case of psychosis is different, and the exact cause isn’t always clear. There are certain
illnesses that cause psychosis, however. There are also triggers like drug use, lack of sleep,
and other environmental factors. In addition, certain situations can lead to specific types of
psychosis developing.
Illnesses
Illnesses that can cause psychosis include:
 brain diseases such as Parkinson’s disease, Huntington’s disease, and some chromosomal
disorders
 brain tumors or cysts
Some types of dementia may result in psychosis, such as that caused by:
 Alzheimer’s disease
 HIV, syphilis, and other infections that attack the brain
 some types of epilepsy
 stroke
Risk factors for developing psychosis
It’s not currently possible to precisely identify who is likely to develop psychosis. However,
research has shown that genetics may play a role.
People are more likely to develop a psychotic disorder if they have a close family member,
such as a parent or sibling, who has a psychotic disorder.
Children born with the genetic mutation known as 22q11.2 deletion syndrome are at risk for
developing a psychotic disorder, especially schizophrenia.
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Types of psychosis
Some kinds of psychosis are brought on by specific conditions or circumstances that include
the following:
Brief psychotic disorder
Brief psychotic disorder, sometimes called brief reactive psychosis, can occur during periods
of extreme personal stress like the death of a family member. Someone experiencing brief
reactive psychosis will generally recover in a few days to a few weeks, depending on the
source of the stress.
Drug- or alcohol-related psychosis
Psychosis can be triggered by the use of alcohol or drugs, including stimulants such as
methamphetamine and cocaine. Hallucinogenic drugs like LSD often cause users to see
things that aren’t really there, but this effect is temporary. Some prescription drugs like
steroids and stimulants can also cause symptoms of psychosis.
People who have an addition to alcohol or certain drugs can experience psychotic symptoms
if they suddenly stop drinking or taking those drugs.
Organic psychosis
A head injury or an illness or infection that affects the brain can cause symptoms of
psychosis.
Psychotic disorders
Psychotic disorders can be triggered by stress, drug or alcohol use, injury, or illness. They
can also appear on their own. The following types of disorders may have psychotic
symptoms:
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Bipolar disorder
When someone has bipolar disorder, their moods swing from very high to very low. When
their mood is high and positive, they may have symptoms of psychosis. They may feel
extremely good and believe they have special powers.
When their mood is depressed, the individual may have psychotic symptoms that make them
feel angry, sad, or frightened. These symptoms include thinking someone is trying to harm
them.
Delusional disorder
A person experiencing delusional disorder strongly believes in things that aren’t real.
Psychotic depression
This is major depression with psychotic symptoms.
Schizophrenia
Schizophrenia is a lifelong disease that is generally accompanied by psychotic symptoms.
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CASE HISTORY 01
Name: Miss A
Age: 72 Yrs
Gender: Female
Marital status: Married
Education level: No
Religion: Hindu
Occupation: No
Type of family: Joint
Socio economic status: Upper
Type of referral: Voluntary
Residential address: No
Informants: Son
Chief complaints
 Decrease in sleep
 Decrease food intake suspicious
 Scaring of wises
 Anger
 Wondering behavior
 Hesitation
 Psychomotor activity increase
Nature of illness:
 Duration: 4-5 months

 Course: Continuous
 Progress: Deteriorating
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History of present illness
Patient was apparently normal 4 month ago. She had developed decrease in sleep,
decrease in food intake. It is increased in since 4 month. He had developed Anger
outburst difficulty to control his and easily get irritable in minor matters. He had
developed decreased appetite since 4 month.
He had developed lack of interest and concentration in daily routine activity. She
had developed wondering behavior & Hesitation. She is not able to concentrate on her
family since 4month.
She had developed psychomotor activity since 4 month.
Past history
No past history.
Negative history
No negative history
Medical history
No history of any medical illness or injury.
Family history
No history of medical or psychiatric is reported in the family.
Physical illness during childhood:-
No history of physical illness during childhood
Occupational: -
No occupation
Sexual history: -
He has no problem in to this respect.
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Premorbid personality
Social relations
She had good relationship with his family. The relationship was good but, with
neighbor society his relationship was average he could not mingle with others.
Intellectual activities
Her intellectual activities were normal.
Character
In respect to responsibilities, her attitude was good she was very rigid, low self
confidence.
Mental Status Examintion
She was well kept and tidy, had self-care, eye to eye contact was good, and
maintained cleanliness. She was not mingling with others patients, doctors and nurses. she
was thinking that they will look at him and talk about him. Her facial expression and posture
are restless. Her dresses were appropriate. Touch with appearance surrounding is present. Her
attitude towards the examination is cooperative. Rap out easily
Psychomotor activity:
Psychomotor activity increased.
Speech:
The patient used to answer the questions only. Her speeches were spontaneous. Her
reaction on time. Speech was relevant and coherent
Mood
Range: Constricted
Reactivity: Normal
Stability: Stable
Congruence: Congruent
Thought:
Content: Idea of reference and suspiciousness
Delusion: Persecutory and reference.
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Perception: -
She has illusion and hallucination, was asserted through vision, hearing. With respect
to auditory hallucination, multiple voice, familiar voice. Hallucinations were of (her husband
who has is already dead and she was hearing her husband voice). They were unpleasant in
nature, with commanding, abusive, threatening and fear.
Cognitive Function
The patient orientation and memory is in rapid and of time, place and person well
oriented.
Attention and concentrations: -
The patient has normal attention and concentrations.
Intelligence: -
Her intelligence is average
 General information: Average.

 Comprehension: Average.
 Arithmetic: Average.
Abstraction: -Average.
 Similarities - The patient easily finds common factors among the words given.
 Difference - Able to find difference between two words
Proverbs:
When proverbs were given to him, he gave proper explanations.
Insight:
The patient is not aware of her illness. Hence, the insight is absent Complete denial
symptoms.
Judgment:
The patient had the social responsibilities.
Summary
She was normal but from past four months she has developed decreased in sleep,
deceased is food intake, suspicious, scaring of voice, anger, restlessness, wondering behavior,
psycho motor activity increased. The above mentioned symptoms suggested that the patient is
suffering from Late on-set psychosis.
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Diagnosis:
As per the symptoms and examinations of the patient it suggests that the patient is
suffering from Psychosis. Hence it is above 60 years so diagnosed as Late on-set psychosis.
Treatment
It’s important to get treated early, after the first episode of psychosis. That will help keep the
symptoms from affecting your relationships, work, or school. It may also help you avoid
more problems down the road.
You doctor may recommend Coordinated Specialty Care (CSC). This is a team approach
towards treating schizophrenia when the first symptoms appear. It combines medicine and
therapy along with social services and employment and educational interventions. The family
is involved as much as possible.
Just what your doctor recommends will depend on the cause of your psychosis.
Your doctor will prescribe antipsychotic drugs -- in pills, liquids, or shots -- to lessen your
symptoms. He will also recommend that you stop using drugs and alcohol.
You might need to get treated in a hospital if you’re at risk of harming yourself or others, or
if you can't control your behavior or do your daily activities. Your doctor will check your
symptoms, look for causes, and suggest the best treatment for you.
Some clinics and programs offer help just for young people.
Psychotherapy
Counseling can also help manage psychosis.
Cognitive behavioral therapy (CBT) can help you recognize when you have psychotic
episodes. It also helps you know whether what you see and hear is real or imagined. This
kind of therapy also stresses the importance of antipsychotic medications and sticking with
your treatment.
Supportive psychotherapy helps you learn to live with and manage psychosis. It reinforces
healthy ways of thinking.
Cognitive enhancement therapy (CET) uses computer exercises and group work.
Family psycho education and support involves your loved ones. It helps you bond and
improves the way you solve problems together.
Coordinated Specialty Care (CSC) implements a team approach in treating psychosis when
it is first diagnosed. CSC combines medication and psychotherapy with social services and
employment and educational intervention.
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Introduction
Bipolar affective disorder is a mental health condition that causes severe mood swings. Your
mood can vary from excitement and elation, known as mania, to depression and despair.
Bipolar affective disorder is also called by the name manic-depressive illness (MDI), is a
common, severe, and persistent mental illness. This condition is a serious lifelong struggle
and challenge.
Signs and symptoms
Bipolar affective disorder is characterized by periods of deep, prolonged, and profound

depression that alternate with periods of an excessively elevated or irritable mood known as
mania.
Manic episodes are feature at least 1 week of profound mood disturbance, characterized by
elation, irritability, or expansiveness (referred to as gateway criteria). At least 3 of the
following symptoms must also be present
Grandiosity
Diminished need for sleep
Excessive talking or pressured speech
Racing thoughts or flight of ideas
Clear evidence of distractibility
Increased level of goal-focused activity at home, at work, or sexually
Excessive pleasurable activities, often with painful consequences
Hypomanic episodes are characterized by an elevated, expansive, or irritable mood of at

least 4 consecutive days’ duration. At least 3 of the following symptoms are also present
Grandiosity or inflated self-esteem
Diminished need for sleep
Pressured speech
Racing thoughts or flight of ideas
Clear evidence of distractibility
Increased level of goal-focused activity at home, at work, or sexually
Engaging in activities with a high potential for painful consequences
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Major depressive episodes are characterized as, for the same 2 weeks, the person
experiences 5 or more of the following symptoms, with at least 1 of the symptoms being
either a depressed mood or characterized by a loss of pleasure or interest
Depressed mood
Markedly diminished pleasure or interest in nearly all activities
Significant weight loss or gain or significant loss or increase in appetite
Hypersomnia or insomnia
Psychomotor retardation or agitation
Loss of energy or fatigue
Feelings of worthlessness or excessive guilt
Decreased concentration ability or marked indecisiveness
Preoccupation with death or suicide; patient has a plan or has attempted suicide
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CASE HISTORY 02
Name: Mrs. B
Age: 25 yrs
Gender: Female
Number of child: No
Religion: Hindu
Occupation: House wife
Socio economic status: Middle class
Informants:
 Self
 Husband
Chief complaints
 Excessive crying for 1 month

 Irrelevant behavior for 1 month
 Irritability
 Sleeplessness
 Altered behavior
Nature of illness
 Duration: From past 1 year

 Course: Progressive in nature
 Progress: Acute
 Precipitating factor:
Client visited hospital with her husband, complained about his wife’s suffering from
excessive crying and irrelevant behavior since one year but increased since one month.
Before marriage she had attempted of suicide for ten times and she needs her husband to be
with her always.
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Medical history
No medical history found.
Past history
No history of available
Negative history
No history of decrease appetite
No history of trauma
No history of loss of consciousness
No history of seizure
No history of vomiting
Family history
Married last month
Personal history
Birth of the patient is full termed with normal delivery, developmental milestones were
normal, does not had any trauma or injuries in childhood. There was no behavioral problem
during childhood; there is no sleep disturbance, no history of any other psychological
problems. She has completed PUC, and she was working in a textile shop, then she got love
marriage, she built possessive towards her husband since she was in love relationship with
him. Then she was avoided by her parents, she felt bad on herself.
 No history of nail biting
 No history of bed wetting, stammering
 No history of ADHD and conduct disorder
 Diet: mixed
 Appetite: good
 Sleep: disturbed
 No history of substance abuse
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Pre-morbid personality
Social relation: attachment with mother is normal and also has a good attachment
relation with fiends. The patient is said to be adjustable individual.
Mood
Mood being bright and cheerful
Character
He has very well attitude towards his profession. He finds some difficulties in making
his own decision. Interpersonal relationship is normal.
Mental status examination
General behavior: Good
Physical appearance: Proper eye to eye contact, rapport was established easily with the
patient.
Psychomotor activity: Patient has decreased psychomotor activity.
Speech
Speech was relevant and coherent speaks spontaneously, volume, tone and tempo was
normal.
Thought
Thought content of ideas of persecution was low
Mood
Subjectively happy and objectively elevated
Perception
No perceptual disturbances
Cognitive function
Orientation: good and normal
Attention and Concentration: Average
 Digit span test:

 Forward-Able to recall 6 words
 Backward-Able to recall 4 words
 Serial subtraction-Good
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Memory: Good
 immediate memory: Good

 remote memory: Good
Intelligence: Average
 General information- Average

 Comprehension- Normal
 Arithmetic- Normal
Abstraction: Good
 Similarities- Find out

 Difference-Find out
Proverbs-Average
Summary:
To summarize, the client is suffering from excessive worry, about her married life and
family because she got married to inter religion. There are some significant psychological
disturbances are found like mood swings, restlessness, excessive talking and crying. A good
and effective treatment planning leads to help for the client in better way.
Diagnosis: Bipolar affective disorder
Recommendation
 Family Psycho education :

Family Psycho-education (FPE) is an approach for partnering with consumers and
families to treat serious mental illnesses. FPE practitioners develop a working
alliance with consumers and families. The term psycho-education can be misleading.
But in the FPE approach, the illness is the object of treatment, not the family.
 Behavioral and Cognitive Therapy:
- It patient to react differently to situations and bodily sensations that trigger
anxiety.
- It Teaches patient to understand to thinking patterns that contribute to symptoms.
- Patients learn that by changing how they perceive feelings of anxiety, the less
likely they are to have them.
Treatment
Along with medication, use of psychotherapy helps to treat the patient with mood
disorders.
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Psychotherapy
Psychosurgery is an extremely rarely used method of treatment and is

resorted to only in exceptional circumstances.
Psychosocial treatment: although somatic treatment appears to be the

primary mode of management in major mood disorders, psychosocial treatment is also
helpful.
These indications include:
 As an adjunct to somatic treatment

 In mild to moderate case of depression
 Certain selected cases.
With all these things cognitive behavior therapy, interpersonal therapy,
behavior therapy group therapy and supportive therapy can be used.
In the present case, patient have severe level of manic episodes, ECT is
preferable and
Night mares about what happened, hyper vigilance, startling easily, withdrawing from
others, and avoiding situations that remind you of the event.
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INTRODUCTION
Schizophrenia is a serious mental illness that interferes with a person’s ability to think
clearly, manage emotions, make decisions and relate to others. It is a complex, long-term
medical illness, affecting about 1% of Americans. Although schizophrenia can occur at any
age, the average age of onset tends to be in the late teens to the early 20s for men, and the late
20s to early 30s for women. It is uncommon for schizophrenia to be diagnosed in a person
younger than 12 or older than 40. It is possible to live well with schizophrenia.
Symptoms
It can be difficult to diagnose schizophrenia in teens. This is because the first signs can
include a change of friends, a drop in grades, sleep problems, and irritability—common and
nonspecific adolescent behavior. Other factors include isolating oneself and withdrawing
from others, an increase in unusual thoughts and suspicions, and a family history of
psychosis. In young people who develop schizophrenia, this stage of the disorder is called the
"prodromal" period.
With any condition, it's essential to get a comprehensive medical evaluation in order to obtain
the best diagnosis. For a diagnosis of schizophrenia, some of the following symptoms are
present in the context of reduced functioning for a least 6 months:
Hallucinations: These include a person hearing voices, seeing things, or smelling things
others can’t perceive. The hallucination is very real to the person experiencing it, and it may
be very confusing for a loved one to witness. The voices in the hallucination can be critical or
threatening. Voices may involve people that are known or unknown to the person hearing
them.
Delusions: These are false beliefs that don’t change even when the person who holds them is
presented with new ideas or facts. People who have delusions often also have problems
concentrating, confused thinking, or the sense that their thoughts are blocked.
Negative symptoms: are ones that diminish a person’s abilities. Negative symptoms often
include being emotionally flat or speaking in a dull, disconnected way. People with the
negative symptoms may be unable to start or follow through with activities, show little
interest in life, or sustain relationships. Negative symptoms are sometimes confused with
clinical depression.
Cognitive issues/disorganized thinking: People with the cognitive symptoms of

schizophrenia often struggle to remember things, organize their thoughts or complete tasks.
Commonly, people with schizophrenia have anosognosia or “lack of insight.” This means the
person is unaware that he has the illness, which can make treating or working with him much
more challenging.
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Causes
Research suggests that schizophrenia may have several possible causes:
 Genetics. Schizophrenia isn’t caused by just one genetic variation, but a complex
interplay of genetics and environmental influences. While schizophrenia occurs in 1%
of the general population, having a history of family psychosis greatly increases the
risk. Schizophrenia occurs at roughly 10% of people who have a first-degree relative
with the disorder, such as a parent or sibling. The highest risk occurs when an
identical twin is diagnosed with schizophrenia. The unaffected twin has a roughly
50% chance of developing the disorder.
 Environment. Exposure to viruses or malnutrition before birth, particularly in the
first and second trimesters has been shown to increase the risk of schizophrenia.
Inflammation or autoimmune diseases can also lead to increased immune system
 Brain chemistry. Problems with certain brain chemicals, including neurotransmitters
called dopamine and glutamate, may contribute to schizophrenia. Neurotransmitters
allow brain cells to communicate with each other. Networks of neurons are likely
involved as well.
 Substance use. Some studies have suggested that taking mind-altering drugs during
teen years and young adulthood can increase the risk of schizophrenia. A growing
body of evidence indicates that smoking marijuana increases the risk of psychotic
incidents and the risk of ongoing psychotic experiences. The younger and more
frequent the use, the greater the risk. Another study has found that smoking marijuana
led to earlier onset of schizophrenia and often preceded the manifestation of the
illness.
Diagnosis
Diagnosing schizophrenia is not easy. Sometimes using drugs, such as methamphetamines or

LSD, can cause a person to have schizophrenia-like symptoms. The difficulty of diagnosing
this illness is compounded by the fact that many people who are diagnosed do not believe
they have it. Lack of awareness is a common symptom of people diagnosed with
schizophrenia and greatly complicates treatment.
While there is no single physical or lab tests that can diagnosis schizophrenia, a health care
provider who evaluates the symptoms and the course of a person's illness over six months can
help ensure a correct diagnosis. The health care provider must rule out other factors such as
brain tumors, possible medical conditions and other psychiatric diagnoses, such as bipolar
disorder.
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To be diagnosed with schizophrenia, a person must have two or more of the following
symptoms occurring persistently in the context of reduced functioning:
 Delusions
 Hallucinations
 Disorganized speech
 Disorganized or catatonic behaviour
 Negative symptoms
Delusions or hallucinations alone can often be enough to lead to a diagnosis of schizophrenia.

Identifying it as early as possible greatly improves a person’s chances of managing the
illness, reducing psychotic episodes, and recovering. People who receive good care during
their first psychotic episode are admitted to the hospital less often, and may require less time
to control symptoms than those who don’t receive immediate help. The literature on the role
of medicines early in treatment is evolving, but we do know that psychotherapy is essential.
People can describe symptoms in a variety of ways. How a person describes symptoms often
depends on the cultural lens she is looking through. African Americans and Latinos are more
likely to be misdiagnosed, probably due to differing cultural or religious beliefs or language
barriers. Any person who has been diagnosed with schizophrenia should try to work with a
health care professional that understands his or her cultural background and shares the same
expectations for treatment.
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CASE HISTORY 03
Name: Mrs. C
Age: 33 Yrs
Gender: Male
Marital status: Unmarried
Education level: PUC
Religion: Hindu
Occupation: No
Type of family: Nuclear
Socio economic status: Upper
Type of referral: Voluntary
Informants: Self and Mother
Chief complaints
 Disturb in sleep
 Hesitation
 Wondering behavior
 Social Isolation
 Restlessness
 Mirror gazing
 Restlessness
 Psycho motor activity
 Stereotype action
Nature of illness:
 Duration: From past 7 years

 Course: Continuous
 Progress: Deteriorating
 Precipitating factor: Heredity
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Patient was apparently normal from last 7 yrs ago. Gradually he was developed
changes on his behavior such as wondering behavior, social isolation, restlessness and
Stereotype action.
He had developed lack of interest and concentration in daily routine activity. He had
developed Tension and Fear about. He had developed decrease in sleep he will be wake up all
night.
Past history
7yrs back patient was treated under Dr. ABC
Negative history
Rule out organic etiology , history of trauma (injury to health), confusing, seizures,
forgetfulness, loss of consciousness, bowel / bladder incontinence , history of recent physical
illness and substance abuse . Major features that are usually present in the given syndrome ,
other associated major syndromes other psychiatric disorders
Medical history
No history of any medical illness or injury.
Family history
No history of medical or psychiatric is reported in the family.
Birth and early development:-
He was born under normal delivery after 9 months. Mother’s health was normal and
good during the pregnancy period. Baby (Patient) was born at mother’s residence and no
complications during the delivery. No physical illness in postnatal period and milestones of
development were normal as usual.
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Behavior during childhood:-
During the childhood there was no sleep disturbance, thumb sucking, bed wetting,
stammering, ties and mannerism. Also during this period there were no conduct disturbances
in the form of frequent fights, truancy, stealing, lying and gang activities, relationship with
parents, siblings and peers were normal.
Physical illness during childhood:-
No history of physical illness during childhood
School:-
Joined the school at 3 and half years at his native place tile the complexion of
matriculation then studied Degree, During this school days and college days his behavior
were good and performance normal. Even his attitude towards peers and teachers were good
and normal.
Occupational: -
He studied up to PUC and he dint like to study further. Started looking for a job. He
joined an office when he was 22 years old. He worked there for about one year. After that he
quitted the job.
Sexual history: -
Unmarried
Use and abuse of alcohol, tobacco and drugs: -
He is a smoker, alcoholic and non-drug addict.
Social relations
He had good relationship with his family. Regarding his friends the relationship was
good but, with neighbor society his relationship was average he could not mingle with others.
Intellectual activities
His intellectual activities were normal.
Character
In respect to work and responsibilities, his attitude was good he was very rigid, low
self confidence.
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Mental Status Examination
He was un kept and untidy, no self-care, eye to eye contact was bad, and maintained
untidy. He was not mingling with others patients, doctors and nurses. He was thinking that
they will look at him and talk about him. He was fully conscious; He was in tension,
responded to various requirements and situations, responses were normal, very much
attentive, and cooperative.
Psychomotor activity:
Psychomotor activities were increase.
Speech:
The patient used to answer the questions only. The amount of speech was little, with
low tone and low tempo. Reaction time is decreased and the prosody of speech was not
present. Speech was relevant and coherent
Thought:
Presence of formal thought disorder not found in the patient, thought blocking not
present. Obsessions and compulsion, thought alienation not present. Overvalued ideas and
delusions were present.
Perception:
He has illusion and hallucination, was asserted through vision, hearing. With respect
to auditory hallucination, multiple voice, familiar voice. Hallucinations were of third persons
(officers, colleagues at her working place). They were unpleasant in nature, with
commanding, abusive and threatening.
Cognitive Function
The patient has good orientation in respect of time, place and person
Attention and concentrations: -
The patient has normal or good attention and concentrations.
Memory: -
His memory is normal or average.
 Immediate memory: Good.

 Remote memory: Good.
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Intelligence: -
His intelligence is average
 General information: Average.

 Comprehension: Average.
 Arithmetic: Average.
Abstraction: -Average.
 Similarities - The patient easily finds common factors among the words given.
 Difference - Able to find difference between two words
Proverbs:
When proverbs were given to him, he gave proper explanations.
Insight:
The patient is not aware of his illness. Hence, the insight is absent Complete denial
symptoms.
Judgment:
The patient had the social responsibilities.
Summary
He was working fine in the office but after 1 year he left the job. He started
developing Suspiciousness, Irritability, Anger outburst, Impulsivity, Self Hygiene neglected,
Disturbed sleep, Restlessness, Psycho motor activity, Self harm behavior, Indication since
one month. The above symptoms suggested that the patient must be suffering from
schizophrenia
Diagnosis:
As per the symptoms and examinations of the patient it suggests that the patient is
suffering from severe Schizophrenia and psychosis. Hence it is diagnosed as severe
Schizophrenia.
26
Treatments for schizophrenia
With proper treatment, patients can lead productive lives.

Treatment can help relieve many of the symptoms of schizophrenia. However, the majority of
patients with the disorder have to cope with the symptoms for life.
Psychiatrists say the most effective treatment for schizophrenia patients is usually a
combination of:
 medication
 psychological counseling
 self-help resources
Anti-psychosis drugs have transformed schizophrenia treatment. Thanks to them, the

majority of patients are able to live in the community, rather than stay in a hospital.
The most common schizophrenia medications are:
 Risperidone (Risperdal) - less sedating than other atypical antipsychotics. Weight gain
and diabetes are possible side effects, but are less likely to happen, compared with
Clozapine or Olanzapine.
 Olanzapine (Zyprexa) - may also improve negative symptoms. However, the risks of
serious weight gain and the development of diabetes are significant.
 Quetiapine (Seroquel) - risk of weight gain and diabetes, however, the risk is lower than
Clozapine or Olanzapine.
 Ziprasidone (Geodon) - the risk of weight gain and diabetes is lower than other atypical
antipsychotics. However, it might contribute to cardiac arrhythmia.
 Clozapine (Clozaril) - effective for patients who have been resistant to treatment. It is
known to lower suicidal behaviors in patients with schizophrenia. The risk of weight gain
and diabetes is significant.
 Haloperidol - an antipsychotic used to treat schizophrenia. It has a long-lasting effect

(weeks).
27
The primary schizophrenia treatment is medication. Sadly, compliance (following the
medication regimen) is a major problem. People with schizophrenia often come off their
medication for long periods during their lives, at huge personal costs to themselves and often
to those around them.
The patient must continue taking medication even when symptoms are gone. Otherwise they
will come back.
The first time a person experiences schizophrenia symptoms, it can be very unpleasant. They
may take a long time to recover, and that recovery can be a lonely experience. It is crucial
that a person living with schizophrenia receives the full support of their family, friends, and
community services when onset appears for the first time.
28
Introduction
Alcohol Dependency Syndrome (ADS) is not a static disease, defined in absolute terms, but a
disorder which installs along life. It is a phenomenon which depends on the interaction of
biological and cultural factors e.g., religion and symbolic value of alcohol at each
community, that determine how the individual will relate with the substance, within a process
of individual and social learning of the way of consuming alcohol. In this learning process,
one the most significant phenomena are the appearance of abstinence symptoms. When the
person starts ingesting alcohol to relieve these symptoms, a strong association is established
sustaining both the development and the maintenance of dependence.
Identification of the components of Alcohol Dependency Syndrome
According to Edwards, dependence would be "an altered relationship between the person and
his/her way of drinking", in which the reasons why the individual started drinking is added to
those related to dependence. Therefore, dependence becomes a feedback behavior comprising
much more than tolerance and abstinence.
The elements of alcohol dependence syndrome are:
1) Narrowing of the repertoire: Initially, users drink having flexible timetables, quantity
and even type of beverage. As time passes by they start drinking more frequently, up to the
point of consuming alcohol every day, in rising quantities, increasing the frequency of
ingestion and not being worried about the inadequacy of the situations anymore.
In advanced stages subjects consume compulsively, uncontrollably, to relieve the symptoms

of abstinence, without concern with the organic, social or psychological harm. Their
relationship with alcohol become strict and inflexible, in an all-or-nothing pattern.
2) Importance of the behavior of searching alcohol: With the narrowing of the drinking
repertoire, subjects attempt to prioritize the act of drinking, even in unacceptable situations
(e.g., driving vehicles, at work). In other words, drinking becomes the center of the user’s
life, above any other value, health, family and work.
3) Increase in the tolerance to alcohol: As this syndrome evolves, there is the need of rising
alcohol doses to obtain the same effect achieved with lower doses, or the capability of
performing activities despite the high blood concentrations of alcohol.
4) Repeated symptoms of abstinence: When there is decrease or interruption of alcohol

consumption, signs and symptoms of variable intensity arise. At first, they are mild,
intermittent and hardly incapacitating, but in the severest phases of dependence, the most
significant symptoms may be present such as intense trembling and hallucinations.
Descriptive studies have identified three groups of symptoms
Physical: slight tremor on the extremities up to generalized), nausea, vomiting,headache,

cramps, dizziness.
29
Affective: irritability, anxiety, weakness, restlessness, depression.
Sensory perception: nightmares, illusions, hallucinations (visual, auditive or tactile).
5) Relief or avoidance of abstinence symptoms by increasing the ingestion of alcohol:

This is an important symptom of ADS, which is difficult to be identified in its initial phases.
It becomes more evident with the progression of the condition, when patients admit their
drinking in the morning to feel better, as they remained all night without ingesting ethylic
derivate.
6) Subjective perception of the need of drinking: There is a psychological pressure to drink

and relieve the symptoms of abstinence.
7) Reinstallation after abstinence: Even after long periods of abstinence, if patients relapse,
they will rapidly re-establish the former dependence pattern.
30
CASE HISTROY-04
Name: Mr. 4
Age: 39
Gender: Male
Number of children: 2 Children
Religion: Islamic
Occupation: Bussiness
Socio economic status: Middle
Informant:
 Self
 Wife
Chief complaints:
 Fatigue
 Consumption of alcohol
 Turmor
 Tension
 Confusion Behavior
 Forgetfulness
 Worrying
 Irrelevant talk
 Social Isolation
Nature of illness:
 Duration: Form past 16 years

 Course: Episodic in nature
 Progress: Acute
 Precipitating factors: Peer groups influence
31
History of Present Illness
case of Alcoholism since past 16 years, from last 16 yrs months the patient had started
taking excessive alcohol without apparent reason, family members asked to the patient
about this and had a verbal altercation 10 yrs ago, the patient experienced depressed
mood and started to take excessive amount again and shown the abnormal behavior.
Medical history
Patient is suffering from ADS for past 16 years. Family members observed slight
changes in behavior of the patient and took him to XYZ hospital and admitted for a week.
Negative history:
No history of mood problems
No history of suicidal thoughts and attempts
No history of any medical illness or injury
Family history
There is no psychiatric illness in the family
Personal history
Birth of patient is full term normal delivery. He did not have any trauma or injuries in
childhood and had good social competence and social interaction. No history of any other
psychological related problems during childhood. He as a diver, he started to work from
the age of 22. He got married at the age of 23, He has Four children. Elder Daughter is 16
years old, studying in PUC, 2nd daughter is 14 years old, studying in 9th standard,3rd
daughter is 12 years studying 7th standard and last daughter is 10 years studying 5th
standard.
Social relations
He has very good attachment towards his family. He has healthy relationship with
workmates. He is adjustable and cooperative.
32
Character
He has positive attitude towards his profession and he love his job. He likes to have more
friends and spends more time talking too much with friends.
General behavior
The patient is conscious, oriented and attentive.
Physical appearance
Normal body built, well and neatly dressed and personal hygiene is average.
Psychomotor activity
Patient has increased level of psychomotor activity.
Speech
He speaks spontaneously without any disturbance.
Thought
There is craving for alcohol
No formal thought disorder
Mood
Normal
Perception
There is no presence of illusions and hallucination
Cognitive function
Orientation: Good and Normal
Attention and concentration: Average

 Serial subtraction: Normal
33
Memory: Average
 Immediate memory- Good

 Past memory-Good
 Remote memory-Good

 Comprehension-Poor
Abstraction: Good
 Similarities-Finds difficult to find common factors among words given.

 Difference- Able to find difference between two words for which were given.
Proverbs-Gives proper explanations for given proverbs.
Summary
To summarize, the patient is dependent on alcohol since 10 years. He developed

this habit because of influence of friends, some conflicts in his family, failure of love
and over restrictions in family. A good and effective treatment planning leads to help
for the patient in better way.
Diagnosis
As the patient is consuming alcohol on daily basis so this case is diagnosed as the
case of Alcohol Dependency Syndrome.
Recommendation:
 Family counseling:
Family therapy is a type of psychological counseling (psychotherapy) that helps
family members improve communication and resolve conflicts.
 Behavioral therapy:
In behavioral therapy, the goal is to reinforce desirable behaviors and eliminate
unwanted or maladaptive ones. Behavioral therapy is rooted in the principles
of behaviorism, a school of thought focused on the idea that we learn from our
environment. The techniques used in this type of treatment are based on the theories
of classical conditioning and operant conditioning.
34
Treatment
The goals of treatment vary according to the time frame and the scope envisaged.
They will also differ across individual patients and can be revised from time to time.
Immediate goals can be detoxification, treatment of acuter medical sequel and crisis
intervention; short term goals usually target treatment of co-morbid medical or psychiatric
conditions, maintaining abstinence, family reintegration and vocational placement; and the
long-term goals focus on the larger issues of relapse prevention, occupational rehabilitation,
social reintegration, abstinent life style and improvement of quality of life.
A psychosocial intervention can be used as a stand-alone treatment, or in conjunction
with pharmacotherapy. Consistent evidence shows that people who receive these
interventions benefit substantially, and at follow-up show clinically significant reductions in
their alcohol consumption, increases in number of days abstinent, and improvements in
overall functioning.
The most widely used psychosocial approaches that have received consistent
empirical support are:
 Brief interventions
 Motivational approaches
 Various forms of cognitive behavioral therapy, including coping skills training,
behavioral self-management (controlled drinking), relapse prevention and
behavioral couple’s therapy.
And with mentioned above some other effective methods like supportive and
rehabilitation techniques were used.
When it comes to present case, the patient has alcohol dependence problem with only
few associated disturbances such as loss of appetite and sleeplessness. Medications such as
Disulfiram, Naltrexone, Acamprosate can be administered, along with these medicines
psychotherapy is given for effective recovery from present problem.
Psychosocial approaches such as brief intervention strategies can be fallowed because
Brief interventions are effective in reducing alcohol use in people with risky pattern of
alcohol use and in nondependent drinkers experiencing alcohol-related harms and should be
routinely offered to these populations.
In brief intervention strategy should include at least the five components which can
be summarized in the acronyms
 FLAGS (feedback, listen, advice, goals and strategies), the two most crucial of
which are feedback and advice. Alternative acronyms,
 FRAMES (feedback, responsibility, advice, menu, empathy, self-efficacy)
 5As (ask, advise, assess, assist, arrange) with comparable structures for guiding
an intervention, can be used.
Mood swings are apparent in patient so SSRI can be used as mood stabilizer, along
with this cognitive behavior therapy is followed.
35
Introduction
Generalized anxiety disorder (GAD) is a common anxiety disorder that involves constant and
chronic worrying, nervousness, and tension. Unlike a phobia, where your fear is connected to
a specific thing or situation, the anxiety of generalized anxiety disorder is diffused—a general
feeling of dread or unease that colors your whole life. This anxiety is less intense than a panic
attack, but much longer lasting, making normal life difficult and relaxation impossible.
If you have GAD you may worry about the same things that other people do, but you take
these worries to a new level. A co-worker’s careless comment about the economy become a
vision of an imminent pink slip; a phone call to a friend that
isn’t immediately returned becomes anxiety that the relationship is in trouble. Sometimes just
the thought of getting through the day produces anxiety. You go about your activities filled
with exaggerated worry and tension, even when there is little or nothing to provoke them.
Whether you realize that your anxiety is more intense than the situation calls for, or believes
that your worrying protects you in some way, the end result is the same. You can’t turn off
your Relief anxious thoughts. They keep running through your head, on endless repeat.
Signs and symptoms of GAD
Not everyone with generalized anxiety disorder has the same symptoms, but most people
experience a combination of emotional, behavioral, and physical symptoms that often
fluctuate, becoming worse at times of stress.
Emotional Symptoms of GAD include:
 Constant worries running through your head

 Feeling like your anxiety is uncontrollable; there is nothing you can do to stop the
worrying
 Intrusive thoughts about things that make you anxious; you try to avoid thinking
about them, but you can’t
 An inability to tolerate uncertainty; you need to know what’s going to happen in
the future
 A pervasive feeling of apprehension or dread
Behavioural symptoms of GAD include:

 Inability to relax, enjoy quiet time, or be by yourself
 Difficulty concentrating or focusing on things
 Putting things off because you feel overwhelmed
 Avoiding situations that make you anxious
Physical symptoms of GAD include:
36
 Feeling tense; having muscle tightness or body aches
 Having trouble falling asleep or staying asleep because
your mind won’t quit
 Feeling edgy, restless, or jumpy
 Stomach problems, nausea, diarrhea
Treatment for generalized anxiety disorder
If you’ve given self-help a fair shot, but still can’t seem to shake your worries and fears, it
may be time to see a mental health professional. But remember that professiona treatment
doesn’t replace self-help. In order to control your GAD symptoms, you’ll still want to make
lifestyle changes and look at the ways you think about worrying
Cognitive-behavioral therapy (CBT) is one type of therapy that is particularly helpful in the
treatment of GAD. CBT examines distortions in our ways of looking at the world and
ourselves. Your therapist will help you identify automatic negative thoughts that contribute to
your anxiety. For example, if you catastrophize always imagining the worst possible outcome
in any given situation you might challenge this tendency through questions such as, “What is
the likelihood that this worst-case scenario will actually come true?” and “What are some
positive outcomes that are more likely to happen?”.
The five components of CBT for anxiety are:
Education: CBT involves learning about generalized anxiety disorder. It also teaches you
how to distinguish between helpful and unhelpful worry. An increased understanding of your
anxiety encourages a more accepting and proactive response to it.
Monitoring: You learn to monitor your anxiety, including what triggers it, the specific things
you worry about, and the severity and length of a particular episode. This helps you get
perspective, as well as track your progress.
Physical control strategies: CBT for GAD trains you in relaxation techniques to help
decrease the physical over arousal of the “fight or flight” response.
Cognitive control strategies: teach you to realistically evaluate and alter the thinking
patterns that contribute to generalized anxiety disorder. As you challenge these negative
thoughts, your fears will begin to subside.
Behavioral strategies: Instead of avoiding situations you fear, CBT teaches you to tackle
them head on. You may start by imagining the thing you’re most afraid of. By focusing on
your fears without trying to avoid or escape them, you will feel more in control and less
anxious.
37
Medication for anxiety
Medication for GAD is generally recommended only as a temporary measure to relieve

symptoms at the beginning of the treatment process, with therapy as the key to long-term
success.
There are three types of medication prescribed for generalized anxiety disorder:
Buspirone – This anti-anxiety drug, known by the brand name Buspar, is generally
considered to be the safest drug for generalized anxiety disorder. Although buspirone will
take the edge off, it will not entirely eliminate anxiety.
Benzodiazepines – These anti-anxiety drugs act very quickly (usually within 30 minutes to
an hour), but physical and psychological dependence are common after more than a few
weeks of use. They are generally recommended only for severe, paralyzing episodes of
anxiety.
Antidepressants – The relief antidepressants provide for anxiety is not immediate, and the
full effect isn’t felt for up to six weeks. Some antidepressants can also exacerbate sleep
problems and cause nausea or other side effects.
38
CASE HISTORY 05
Name: Mr. E
Age: 40yrs
Gender: Male
Number of children: No
Religion: Hindu
Occupation: - Office Worker
Type of family: Nuclear
Socio economic status: Middle
Informant:
 Self
Chief complaints:
 Increased Palpitation
 Tension
 Fear
 Restlessness
 Sleep Disturbance
 Decrease Hepatite
 Turmor
 Sweating
 Fatigue
 Nausea
 Giddiness
 Increase socio motor activity
 Poor coping skills
39
Nature of illness:
 Duration: Form past one month

 Progress: Acute
Precipitating factors: Peer groups influence
History of Present Illness
Patient was normal but from past one month the patient is undergoing Increased
Palpitation, Tension, Fear, Restlessness, Sleep Disturbance, Decrease Hepatitie, Tumors,
Sweating, Fatigue, Nausea, Giddiness, Increase socio motor activity, Poor coping skills all
the above symptoms looks like GAD. So the patient is Diagnosed as GAD.
Medical history
Patient is suffering from GAD for past one month. He himself observed and came for
a treatment to Prerana Hospital.
Negative history:
No Alcohol consumption.
No Smoking.
Family history
Personal history
Birth of patient is full term normal delivery. He did not have any trauma or injuries in
childhood and had good social competence and social interaction. No history of any other
psychological related problems during childhood. He is working, he started to work from the
age of 23. He got married at the age of 25, He has two children. Elder son is 13 years old,
studying in school and younger daughter is 11 years old, studying in school.
40
Social relations
He has very good attachment towards his family. He has healthy relationship with
workmates. He is adjustable and cooperative.
Character
He has positive attitude towards his profession and he love his job. He likes to have
more friends and spends more time talking too much with friends.
General behavior
The patient is conscious, oriented and attentive.
Physical appearance
Normal body built, well and neatly dressed and personal hygiene is average.
Psychomotor activity
Patient has increased level of psychomotor activity.
Speech
He speaks spontaneously without any disturbance.
Thought
No formal thought disorder
Mood
Normal
Perception
There is no presence of illusions and hallucination
Cognitive function
Orientation: Good and Normal
41
Attention and concentration: Average

 Serial subtraction: Normal
Memory: Average
 Immediate memory- Good

 Past memory-Good
 Remote memory-Good

 Comprehension-Poor
Abstraction: Good
 Similarities-He was able to find common factors among words given.

 Difference- Able to find difference between two words for which were given.
Proverbs-Gives proper explanations for given proverbs.
Diagnosis
As the patient is undergoing with more anxiety level and he himself understood that and
came for a treatment to control his anger and all symptoms mentioned states that the patient is
suffering from GAD. So diagnosed him as GAD.
Recommendation:
 Family counseling:
Family therapy is a type of psychological counseling (psychotherapy) that helps
family members improve communication and resolve conflicts.
 Behavioral therapy:
In behavioral therapy, the goal is to reinforce desirable behaviors and eliminate
unwanted or maladaptive ones. Behavioral therapy is rooted in the principles
of behaviorism, a school of thought focused on the idea that we learn from our
environment. The techniques used in this type of treatment are based on the theories
of classical conditioning and operant conditioning.
42
Treatment
Once GAD develops, it is possible for it become chronic, but can be managed or eliminated
with proper treatment. Both cognitive behavioral therapy (CBT) and medications (such as
SSRIs) have been shown to be effective in reducing anxiety. A comparison of overall
outcomes of CBT and medication on anxiety did not show statistically significant differences
(i.e. they were equally effective in treating anxiety). However, CBT is significantly more
effective in reducing depression severity, and its effects are more likely to be maintained in
the long term, whereas the effectiveness of pharmacologic treatment tends to lessen if
medication is discontinued. A combination of both CBT and medication is generally seen as
the most desirable approach to treatment. Use of medication to lower extreme anxiety levels
can be important in enabling patients to engage effectively in CBT.
Lifestyle
Lifestyle factors including: stress management, stress reduction, relaxation, exercise, sleep
hygiene, caffeine, and alcohol can influence the persistence of anxiety. Stress is a factor that
can trigger anxiety. Therefore, keeping stress levels low through stress management, stress
reduction, and relaxation may be beneficial. Physical activity has shown to have a positive
impact whereas low physical activity may be a risk factor for anxiety disorders.
Therapy
Generalized anxiety disorder is based on psychological components that include cognitive

avoidance, positive worry beliefs, ineffective problem-solving and emotional processing,
interpersonal issues, previous trauma, intolerance of uncertainty, negative problem
orientation, ineffective coping, emotional hyperarousal, poor understanding of emotions,
negative cognitive reactions to emotions, maladaptive emotion management and regulation,
experiential avoidance, and behavioral restriction. To combat the previous cognitive and
emotional aspects of GAD, psychologists often include some of the following key treatment
components in their intervention plan; selfmonitoring, relaxation techniques, selfcontrol
desensitization, gradual stimulus control, cognitive restructuring, worry outcome monitoring,
present-moment focus, expectancy-free living, problemsolving techniques, processing of core
fears, socialization, discussion and reframing of worry beliefs, emotional skills training,
experiential exposure, psychoeducation, mindfulness and acceptance exercises. There exist
behavioral, cognitive, and a combination of both treatments for GAD that focus on some of
those key components. Among the cognitive–behavioural orientated psychotherapies the two
main treatments are cognitive behavioural therapy and acceptance and commitment therapy
(ACT). Intolerance of uncertainty therapy and motivational interviewing are two new
treatments for
GAD that are used as either stand-alone treatments or additional strategies that may enhance
CBT.
43
Cognitive behavioural therapy
Cognitive behavioural therapy (CBT) appears to be useful in the treatment of generalized

anxiety disorder. However, there is still room for improvement because only about 50% of
those who complete treatments achieve higher functioning or recovery after treatment.
Therefore, there's a need for enhancement of current components of CBT. CBT usually helps
one-third of the patients substantially, whilst another third does not respond at all to
treatment.
Medications
An international review of psychiatrists' management of patients with generalized anxiety

disorder (GAD) reported that the preferred first-line pharmacological treatments of GAD
were selective serotonin reuptake inhibitors (SSRIs) (80%), followed by serotonin–
norepinephrine reuptake inhibitors (SNRIs) (43%), and pregabalin (35%). Preferred second-
line treatments were SNRIs (41%) and pregabalin (36%).
44
Report
As a part of my curriculum, I was posted as an Intern for one month (60 hours) in the
Department of Clinical Psychology, Perana Hospital, Mysore. I have interacted with many
patients. I learnt how to take case histories and I have collected few case history form the
inpatient wings.
It was a thankful opportunity that I got and I interacted with lots of patients,
Depression are being the most commonly seen disorders in these days.
Several aspects and risk factors were revealed which influences on these disorders.
Among them one of the major aspects is that most of the patients who are suffering from
these disorders are from low socio-economic background Life style, interpersonal
relationship have significant influences on causing these disorders.
Psycho education should be given to all to make aware of psychological disorder.

Instead of focusing more on medication, it is better to plan an effective intervention to treat
problems through psychotherapy. Cognitive behavior therapy, supportive therapy relaxation
techniques are most widely used techniques to solve any type of psycho pathological
disorders. Better planning and utilization of all the techniques lead to handle any of cases in
an effective way.
45
Reference
http://www.rcpsych.ac.uk/mentalhealthinformation/therapies/cognitivebehaviouraltherapy.as
p.
http://psychecentral.com/ddisorder/bipolar/introduction-to-bipolardisorder/
www.psychiatry.org/paients-families/schizophrenia/what-is-schizophrenia.
www.webmd.com/mental-health/addiction/alcohal-abuse-and-dependence-topic-overview#2.
http://www.webmd.com/bipolar-disorder/guide/understanding-bipolar-disorder-treatment#1
http://emedicine.medscape.com/article/285913-treatment
http://www.mayoclinic.org/diseases-conditions/bipolar-disorder/diagnosis-
treatment/treatment/txc-20308001
http://www.medindia.net/patients/hospital_search/krishna-rajendra-hospital-mysore-
karnataka-2612-1.htm
https://en.wikipedia.org/wiki/Krishna_Rajendra_Hospital
www.counselling-directory-org.uklcounsellor-articals/phobias-a-brief-introduction.
http://psychecentral.com/ddisorder/bipolar/introduction-to-bipolardisorder/
www.helpguide.org/articles/anxiety/anxiety-atracks-and-anxiety-disorder.htm.
www.dailycupofpositivitea.com/wp-content/uploads/2015/11/anxiety.jpg
www.psychiatry.org/paients-families/schizophrenia/what-is-schizophrenia.
www.webmd.com/mental-health/addiction/alcohal-abuse-and-dependence-topic-overview#2.
http://www.webmd.com/bipolar-disorder/guide/understanding-bipolar-disorder-treatment#1
46
Appendix
National Institute of Mental Health and Neuro Science proforma for Case History
taking
History taking:
Personal data:
Name, Age, Gender, Education level, marital status, Religion, Type of family, Socio
economic status, Residential address
Informant mention here the source of information, relationship of the informant to the patient,
intimacy and length of acquaintance with the patient and reliability of the information. It is
often necessary to obtain information from more than one source. In certain types of illness
like psychoses, relatives will be able to provide more reliable information while in neurotic
illness, the patient would be the best informant when information is collected from more than
one source. Do not change the accounts of several informants into one, but record them
separately.
Complaints and their duration
Record the complaints in a chronological order. Do not write a long list of complaints,
present the salient disturbances in the different areas of functioning, while some
patients/relatives may present an elaborate list of complaints, others might not spontaneously
report their difficulties unless more direct questions are posed. Hence use your skills and
discretion in eliciting the complaints.
Give detailed and coherent account of the symptoms from the onset to the time of
consultation including their chronological evolution and course. Specific attention must be
paid to the following.
Onset: note if the onset of the symptoms are abrupt (within 48 hrs), acute (that is
developing within few hrs- 2 weeks), sub-acute (few weeks), or insidious (few weeks to few
months).
Precipitating factors: enquire about any precipitating events. These could be

physical or psychological in nature. Ascertain whether the events clearly preceded the illness
or were consequences of the illness.
Coarse of illness: the course of illness can be episodic (discrete symptomatic periods
with intervening periods of normalcy), continuous or fluctuating (periodic exacerbations of a
continuous illness). Also a different pattern of symptoms may evolve in a continuous illness.
47
For example illness, while in the later stages apathy and emotional blunting might be
prominent.
Associated disturbances: enquire should also be made of impairment in other area of

functioning, these include disturbances in sleep, appetite, weight, sexual life, social life and
occupation. The specific nature of the disturbances and the degree of suitability should be
recorded.Lastly, certain historical details must be routinely enquired into, to rule out an
organic a etiology. These include history of trauma, fever, headache, vomiting, confusion,
disorientation, memory disturbance, history of physical illness like hypertension/diabetes and
history of substance abuse, while these details are important regardless of the nature of
presentation, they are particularly important in the elderly.
Family history: give a description of the family members. The description should
include information as to whether they are living or dead, age education, occupation, marital
status, personality and relationship with the patient. Describe the socio economic condition of
the family, leadership pattern, role functions and communication with the family. Enquire
about the physical and/or psychiatric illness in the family and record in detail.
Personal history
1. Birth and early development

Record the details of prenatal, natal and post natal periods, was the birth at full term?
Whether delivered in hospital or at home? Any complications during delivery? Any physical
illness in post natal period? Ascertain whether milestones of development were normal or
delayed.
2. Behaviour during childhood

Enquire about sleep disturbances, thumb sucking, and nail biting, temper tantrums,
bed wetting stammering, tics, and mannerisms. Look for conduct disturbances in the form of
frequent fights, truancy, stealing, lying, and gang activities. Also enquire about relationship
with parents, siblings and peers.
3. Physical illness during childhood

Record physical illness suffered in childhood. Enquire specifically regarding epilepsy,
meningitis and encephalitis.
4. School
Enquire about age of beginning and finishing school, type of school attended,
scholastic performance and attitude towards peers and teachers.
5. Occupation
Age of starting work, jobs held in chronological order, work satisfaction, competence
and future ambitions.
48
6. Menstrual history
Enquire about age of menarche, reaction to menarche, regularity of periods,
dysmenorrhea, menorrhagia/oligomenorrhea, and emotional disturbances in relation to
menstrual cycle.
7. Sexual history
Enquire about age at onset of puberty, level of knowledge regarding sex and mode of
gaining the same, masturbatory practices, anxiety related sexual fantasies/practices.
Homosexual/hetero sexual fantasies, inclinations and experiences and extra marital
relationships.
8. Marital history
Enquire regarding age at the time of marriage, whether arranged by elders or by self,
was there mutual consent of the partners, age education, occupation health and personality of
partner, quality of marital relationship, any separation or divorce. Note the number of
children, their ages and health status.
9. Use and abuse of alcohol, tobacco and drugs

Enquire about smoking and drinking pattern and abuse of other drug like
cannabis, opiates, barbiturates etc.
In this description of the personality prior to the beginning of the mental illness, do
not be satisfied with a series of adjectives and epithets, but give illustrative anecdotes and
detailed statements. Aim at the picture of an individual, not a type, the following is a merely a
collection of hints, not a scheme. It will not be possible to cover all the items listed in the
course of the first interview, but an attempt should be made, particularly cause os neuroses or
affective disorder, to elicit evidence about all aspects of premorbid personality on the course
of explanations extending over a period.
1.Social relations: the family(attachment, dependency), to friends, groups, societies,

clubs to work and workmates (leader or follower, organiser, aggressive, submissive,
ambitious, adjustable, independent)
2.Intellectual activities: hobbies and interest books, plays, pictures, preferred,

memory, observation, judgement, critical faculty.
3.Moods: bright and cheerful or despondent, worrying or placid, strung or calm and
relaxed, optimistic or pessimistic, self-depreciative or satisfied, mood stable or unstable, with
or without any occasion.
CharacterAttitude towards work and responsibilities: welcomes or is, by

responsibility, makes decisions easily or with difficulty, haphazard and slapdash or
methodological and meticulous, rigid or flexible, cautious, foresightful and given to checking
or impulsive and slipshod, preserving and determined or easily bored discouraged.
49
Interpersonal relationships: self-confident or shy and timid, intensive or touchy and
sensitive to criticism, trusting or suspicious and jealous, emotionally controlled or quick
tempered and irritable, tactful or outspoken, enjoys or shuns self-display, quiet and restrained
or expressive and demonstrative in speech and gesture, interest and enthusiasm, sustained or
evanescent, tolerant or intolerant of others, adoptable or rigid
1. Energy and initiative: energetic or sluggish, output sustained or fitful,

fatigability any regular or irregular fluctuations in energy or output
2. Fantasy life: frequency and content of day dreaming
3. Habits: eating, alcohol consumption, self-medication with drugs and other
medicines specify amounts taken recently and earlier tobacco consumption.
Sleeping, excretory functions.
A systematically conducted mental status examination is an important component of

case taking, it is essential or record the observations properly, whenever positive findings are
obtained, they should be described in detail. It is not adequate to say delusions present or
hallucinations. MSE has to be repeated several times during the course of the illness to know
the evolution of symptoms, effectiveness of the treatment etc. the time frame covered by the
MSE is restricted to the hour of observation, but extends longer while the following account
highlights the major components of MSE, detail should be obtained from other sources cited.
1. General behavior
Description as complete accurate, life like as possible, of the observation of ward staff
or your own following points may be considered, though not exclusivelyEnquiry about the
ways of spending the day eating. Sleeping. Cleanliness in general, self-care, hair and dress,
behavior towards other patients, doctors and nursing staff. does the patient look ill? Note
whether the patient is fully conscious, stupors or comatose is he in touch with surroundings.
Is the patient relaxed or tensed or restless/ is he slow or hesitant? How does he respond to
various requirements and situations? Are there abnormal responses to external events? Can
his attention be held or diverted? Is the patient is cooperative? Can adequate rapport be
established? Does the patient maintain adequate eye contact? Does the patient’s behavior
suggest that he is oriented or disoriented? Note the presence of any tics or mannerisms. Note
the presence of any catatonic behavior.
2. Psychomotor activity
Note if the psychomotor activity is increased, decreased or normal.
50
3. Speech:
Note here the form of utterances rather than the content does the patient speak
spontaneously or only in response to questions?
Is the amount of speech little or excessive? Is it high toned or low toned? Is the
tempo fast or slow?
Is the reaction time increased or decreased?
Is the prosody of speech maintained?
Is it relevant?
Is it coherent?
Describe under these headings, relevance, coherence, volume, tone, tempo,
reaction time.
4. Thought:
Examine thought processes with respect to
Form: Presence of formal thought disorder.
Stream: Flight if ideas, retardation of thinking circumstantiality, preservation,
thought blocking.
Possessions: Obsessions and compulsions, thought alienation. With respect to
obsessions, elicit their nature – ideas doubts, imagery, impulses and phobias. Similarly
clarify the nature of compulsive acts checking, counting or washing are these
‘controlling’ compulsions of ‘yielding’ compulsions.
Content: Look for the presence of overvalued ideas and delusions before
making an inference, a detailed description of the phenomenon must be given. Note
whether the delusion is single or these are multiple delusions, the type of delusion
(grandiose, persecutory, nihilistic etc), the exact content of the delusions, whether they
are fleeting or fixed, whether they are well systematized or poorly systematized and
whether they are mood congruent or not Enquire about worries and preoccupations,
hypochondriacal and somatic symptoms. Depressive ideation, ideas of worthlessness,
guilt, hopelessness and suicidal ideas must be enquired and recorded.
5. Mood:
This should be assessed by subjective report and objective evaluation;
assessment should be both longitudinal (mood) and cross-sectional (affect). Description
should be given regarding the following components’ the quality or emotion
(happiness, sadness, anxiety etc) the intensity or depth of emotional experience, the
range of effective response, reactivity (changes in emotion in relation to environment
factors), diurnal variation, congruity (in relation to thought processes) and
appropriateness (in relation to situations). Note any evidence of liability (rapid and
extreme changes in emotion).
51
6. Perception:
Record the presence of illusions and hallucinations. Enquiry should be made
into the following modalities, vision, hearing, smell, touch, taste, pain and deep
sensations vestibular sensations and sense or presence, record also the presence of
special varieties of hallucinations like functional hallucinations synaesthesia and
autoscopy . Detailed descriptions of the actual experience should be obtained For
example, with respect to auditory hallucinations enquiry whether the hallucinations are
verbal or nonverbal continuous or intermittent, single voice or multiple voices, familiar
voice; unfamiliar. First person, second person or third person; pleasant or unpleasant. If
unpleasant, whether commanding, abusive or threatening; relationship to
hallucinations; whether mood congruent. Distinguish hallucinations from imagery and
pseudo-hallucinations.
Other perceptual disturbances that must be enquired into include heightened
perception, dulled perception, depersonalization/de-realization experiences in the
perception of the
7. Cognitive Functions:
Insight: test the patient’s level of awareness of his illness, Does he think he is
not ill at all (absence of insight?) Does he recognize the presence of illness but gives
explanation in physical terms (partial insight)? Does he fully realize the emotional
nature of his illness and the cause of his symptoms (Insight present)?
Summary
The purpose of a summary is to provide concise description of all the important
aspect of the case to enable others who are unfamiliar with the patient to grasp the
essential feature of the problem the summary should be presented in the same format as
described in the previous pages.
Formulation
This is the student’s own assessment of the case rather than as restatement of
the facts. Its length layout and emphasis will very considerably from one patient to
another. It should always include a discussion of the diagnosis, of the etiological factors
which sees important, a plan of management and an estimate of the prognosis,
regardless the uncertainly or complexity of the case, a provisional diagnosis should
always be specified using the ICD.Investigation treatment and follow-up
Biochemical, radiological or psychometric investigations should be carried be
out wherever. Appropriate all aspects of management viz. physical, psychological and
social interventions should be included in the treatment package though the relative
emphasis may differ from case to case.
Progress notes should be systematically recorded.
52
CLINICAL ASSESSMENT OF COGNITIVE FUNCTIONS
Clinical assessment includes the areas of
1. Orientation
2. Attention and Concentration
3. Memory
4. Intelligence
5. Judgment.
ORIENTATION:
There aspects are described to time, place and person the following questions
may be asked in the relevant areas:
Time:
1. Approximately what time of the day is it? (If the patient is unable to
reply a more specific question may be asked).
2. Is it morning, afternoon, evening or night?( In addition further
questioning may be done to assess estimation of time)
3. Approximately how long is it since you had breakfast/lunch tea/dinner?
(OR) Approximately how long have I been talking: to you?
4. What is the day today? (Days of week).
5. What is the date (day of the month, month, and year) today?
Place:
1. What place is this? (If the answer is not forthcoming, a specific question
is asked)
2. Is this a school, office, hospital, restaurant etc., (If the patient says it is a
hospital details may be asked depending on background).
Person:
1. Orientation to self is tested by asking the identity of the patient.
2. Inquiring about the identity of the patient’s relatives or family members.
ATTENTION AND CONCENTRATION:

Tests used in clinical situation include:
1. The digit span test.
2. Serial subtraction.
3. Days or months forward to backward.
53
1. Digit Span Test:
a. Forward:
Patient is given the following instructions: I will be saying some digits,
listen to me carefully when I finish saying them, you will have to repeat them in
the same order the examiner after instructing the patient.
A. Gives an example (for example if I say 3, 7).
B. Reads digits at the rate of one per second to the patient.
C. Notes whether the immediate response of the patient is correct or incorrect.
The following digits may be used:
5-7-3 4-1-7
5-3-8-7 6-1-5-8
1-6-4-9 -5 2-9-7-6-3
7-2-5-9-4-8-3 4-7-1-5-3-8-6
4-7-2-9-1-6-8-5 9-2-5-8-3-1-7-4
The digit span is the highest number of digits repeated correctly.
The same digits should not be presented more than once- if the patient cannot
repeat a particular number of digits on one trial, a 2nd trial with the same number of
digits is given and credit is given if the response is correct.
b. Backward:
The patient is instructed as follows: I will be saying some digits listen to me
carefully and repeat them after me in a reversed order, for example if I say 2-5; you
have to say 5-2. The procedure is the same as for digits forward:
- The same digits be repeated not be used as for the forward test.
- No digit backward score is the highest number of digits correctly recalled
backward after a maximum of 2 trials.
SERIAL SUBSTRACTIONS:
Increasingly difficult tests are presented. The examiner a) instructs the patient,
b) gives an example of how to perform task, c) notes the responses verbatim and d)
notes the times taken in seconds.
TASK: Correct response and the limit.
20-1 20 to 0 reversed in 15 secs.
40-3 40,37,34,31 etc in 60 secs.
100-7 100,93,86,79, etc in 120 secs.
3) Days or months may be asked for in backward to the patient who is familiar
the correct order.
54
MEMORY:
Assessment includes immediate, recent and remote memory.
(a). Immediate memory- tested by digit span test.
(b).Recent memory – tested by:
1. Address test, an address consisting of about 4-5 facts. Which is not known to the
patient is slowly read to the patient after instructing him to attend to the examiner. He is
engaged in conversation (to avoid rehearsal) and the response is noted verbatim.
Recall is asked for after 3-5 minutes.
b). Asking the patient to recall events in the last 24 hours e.g details of the time and
amount in a meal, visitors to the hospital from an inpatient. Responses given by the
patient should be noted of any cross-checked from reliable source.
c).Remote memory: Information on life events: relevant to the patient’s background
and answers should be cross checked.
INTELLIGNECE
This includes the areas of general information, comprehension, arithmetic and
vocabulary,
General Information: information relevant to the patient’s literacy age or
occupation may be asked e.g. in literate.
a) Name of prime Minister.
b) 5 rivers, cities or states.
c) Capitals of countries.
d) Current events (major)
For illiterates:
a) Seasons.
b) Crops of fruits growing particular seasons.
c) Prices of food grains or food items.
d) Prices of land.
COMPREHENSION:
The ability to understand is questions asked during an interview is index.
Specifically the following questions of increasing difficulty may be asked:
1. What will you do when you feel cold?
2. What will you do if it rains when you start to work?
3. What will you do when you miss the bus when you are on a journey?
4. What will you do when you find on your that it will be late by the time
you ready your work spot?
5. Why should we be away from bad company?
55
Arithmetic:
The following questions may be asked with increasing time units.
1. How such is 4 rupees and 5 rupees?
2. I borrowed 6 rupees from a friend and returned 2 rupees, how much do I
still owe to him?
3. If a man buys cloth for 12 rupees and gives a shopkeeper 20 rupees, how
much change would he get back?
4. How many pencils can you buy for 2 rupees if one pencil costs quarter of a
rupee (or 25 paise)?
5. If 18 boys are divided into groups of 6, how many groups will there be?
Time limits: 1 to 3, 15 secs
4to 5, 30 secs.
Correct answer: 1).9 2).4 3). 9 4).8 5).3
Abstraction:
Tested by a similarities, differences and proverbs
Similarities: The patient is given the following instructions.
I will be giving you some pair of words. You have to tell me in what way they
are alike, what is common between them, or what the similarity between them is.
Orange - Banana (fruits).
Dog - Lion (animals).
Eye - ear (sense organs).
North - west (directions).
Table - chair (items of furniture).
Correct responses i.e. abstract responses are given in brackets.
Differences being an easier task is always presented before similarities.
Difference:
The instructions are as follows: I will be presenting to you some parts of words.
Listen carefully and tell me in what they are different from each other.
Stone - Potato (not edible-edible / hard-soft).
Fly - Butter (small-large/not colorful -colorful)
Cinema - Radio (Radio-visual-audio).
Iron - Silver (heavy-light-bright).
Praise - Punishment (Positive –negative/pleasant-unpleasant).
Proverbs:
The patient is asked the following questions.
a) Whether he knows what a proverb is,
b) An example of a proverb and what it means.
If it is clear that the patient has the concept of a proverb, the following may be
asked.
1. Slow and steady wins the race.
2. Barking dog’s bits seldom. Etc.
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INTRODUCTION

PRERANA HOSPITAL is a Multi-Specialty-Neuro Psychiatry, De-Addiction and

The Hospital offers the Following Services.

 Psychiatric Team comprising of psychiatrist clinical psychologists, Child guidance

The psychology department of Prerana Hospital, De-Addiction and Rehabilitation center

Symptoms of psychosis include:

Illnesses that can cause psychosis include:

Risk factors for developing psychosis

Brief psychotic disorder

Drug- or alcohol-related psychosis

This is major depression with psychotic symptoms.

Schizophrenia is a lifelong disease that is generally accompanied by psychotic symptoms.

Marital status: Married

Type of family: Joint

Socio economic status: Upper

Type of referral: Voluntary

 Duration: 4-5 months

She had developed psychomotor activity since 4 month.

No history of any medical illness or injury.

No history of medical or psychiatric is reported in the family.

Physical illness during childhood:-

No history of physical illness during childhood

He has no problem in to this respect.

Her intellectual activities were normal.

Mental Status Examintion

Psychomotor activity increased.

Content: Idea of reference and suspiciousness

Delusion: Persecutory and reference.

Attention and concentrations: -

The patient has normal attention and concentrations.

Her intelligence is average

 General information: Average.

When proverbs were given to him, he gave proper explanations.

The patient had the social responsibilities.

Counseling can also help manage psychosis.

Signs and symptoms

Bipolar affective disorder is characterized by periods of deep, prolonged, and profound

Diminished need for sleep

Excessive talking or pressured speech

Racing thoughts or flight of ideas

Clear evidence of distractibility

Increased level of goal-focused activity at home, at work, or sexually

Excessive pleasurable activities, often with painful consequences

Hypomanic episodes are characterized by an elevated, expansive, or irritable mood of at

Grandiosity or inflated self-esteem

Diminished need for sleep

Racing thoughts or flight of ideas

Clear evidence of distractibility

Increased level of goal-focused activity at home, at work, or sexually

Engaging in activities with a high potential for painful consequences

Markedly diminished pleasure or interest in nearly all activities

Significant weight loss or gain or significant loss or increase in appetite

Psychomotor retardation or agitation

Loss of energy or fatigue

Feelings of worthlessness or excessive guilt

Decreased concentration ability or marked indecisiveness

Marital status: Married

Occupation: House wife

Type of family: Joint

Socio economic status: Middle class

 Excessive crying for 1 month

 Duration: From past 1 year

History of present illness

No medical history found.