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CASE STUDY-A
SOCIO DEMOGRAPHIC DATA
Name: A Age: 24 years Gender: Male Marital Status: Unmarried Religion: Islam SES: Middle Class Occupation: Driver Domicile: Rural Informants: Patients, Mother Reliability: Reliable
PRESENTING COMPLAINTS
- Tension
- Feeling dirty
- Difficulty in swallowing the food
- Palpitation of the chest
- Irresistible desire to wash hands with soap, whenever he washes
- Feels discomfort after eating porotta
HISTORY OF PRESENTING COMPLAINTS
The patient was absolutely normal till last year. He was working as a driver in Qatar. He could not cope with the situations at Qatar. He said that he became tensed there. So he left Qatar after 45 days. On the way back, he got down at Oman and there he felt that he will miss his flight to India. This incident made him more tensed.
When he came home, he started to bath only with water from a house. He could not bath without using the water from house and soap. Also he started to wash his hands with soap whenever he washes hands due to an unhygienic feeling. A difficulty while swallowing
developed with him, and became tensed and restless after eating portals. He developed palpitation of chest. All these symptoms started after stopping bathing with the house.
HISTORY OF PAST ILLNESESS
- History of seizures after a fright while bathing in pond water.
- No significant medical illnesses were reported.
TREATMENT HISTORY
One month before he consults a psychiatrist for tension. He took medicine and after two week he stopped medication. There is no other significant treatment history.
PERSONAL HISTORY
Normal institutional delivery. Normal birth weight. No maternal emergencies during birth. Mile stones were normal.
Separation anxiety reported in the primary classes. Co-operative with the peer group. Studied up to the X standard, but failed in the final exam. He had also failed in the VIIth standard for once.
Started smoking at the age of 16 years with friends. Friends offered him cigarettes. The habit of alcoholic drinking started at the age of 22 nd. But the drinking habit is occasional. He had also an occasional habit if betel chewing using pan parag.
He had got a first prize in a short story writing competition conducted by Mathrubhumi weekly. He had also worked as an associate director for a tele film in a local channel. He had the habit of reading books.
EDUCATIONAL HISTORY
He studied up to the X thstandard, but he failed in the final exam. He had failed in the VIIth standard for once.
Combed hair. Co-operative. Eye to eye contact is maintained. Rapport was established. Psychomotor activity is normal. SPEECH Audible, Normal , Productive and coherent speech. Reactive Time- Normal. MOOD Subjective- ‘Pleasant’ Objective- Anxious affect. THOUGHT PROCESS
Feels that body is not clean.( obsession thoughts- contamination)
PERCEPTION No perceptual disturbances were found.
STATE OF CONSCIOUSNESS Conscious ATTENTION AND CONCENTRATION Attention and concentration were aroused and maintained.( In digit span test ) MEMORY
Immediate- Present. ( digit forward test , ) Recent- Present. ( recollecting recent event ) Remote- Present.( recollecting past event ) INTELLEGENCE Average ( in general-arithmetic ) General knowledge- Average. Abstract Thinking- Present.( proverb testing ) INSIGHT Personal- Present Social- Present. True emotional insight ( grade – 6)
SUMMARY AND DIAGNOSTIC FORMULATION
The presenting complaints of the patient were tension, irresistible desire to bathe with water from the hose, difficulty in swallowing and palpitation in the chest. He was found anxious. His family and personal history all are normal and there is one significant psychiatric history in family, mother has mental illness , pre morbidly well adjusted and sociable. Science one year he became very anxious about hygiene. he started to wash his hands with soap. He frequently washing his hands due to an unhygienic feeling. And became tensed and restless after eating portals. He developed palpitation of chest. All these symptoms started after stopping bathing with the house.
On MSE, he is having disturbances in the thought process such a feeling of contamination(obsession ) and a compulsion to bathe with water from a hose and tendency to wash hands with soap whenever he washes. Rest of the mental functions are normal. He was found to be anxious and restless.
DIAGNOSIS
Clinical feathers of patent meeting the DSM-IV-TR and ICD- 10 Diagnostic Criteria for Obsessive-Compulsive Disorder. ( A - Either obsessions or compulsions (- Obsession -Contamination, compulsion- reaped washing of hand ); B - At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. C- The obsessions or compulsions cause marked distress, are time-consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships. D - The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. E- no other axis - disorders). No other co-morbid disorders.
MANAGEMENT
CASE STUDY-B
SOCIO DEMOGRAPHIC DATA
Name : B Age : 29 yr Gender : Male Religion : Hindu Domocile : Rural Occupation : Teacher Marital Status : Un married Informants : Patient, Brother, and Father
PRESENTING COMPLAINTS
- Mood off
- swelling in the abdomen
- pain in the abdomen
- Irritability
- Suicidal thoughts
- Desperate Mood HISTORY OF PRESENTING COMPLAINTS
Complaints started 4 years back. He had a swelling in the abdomen and pain in the abdomen. He underwent endoscopy. He had difficulty in breathing while sleeping in the night. He became irritable and restless while taking classes in the college. He consulted a neurologist and he prescribed some medicines. He used to make conflicts with other family members and abuses them. He became irritable with the partners of his institution and withdrawn his share. When he had stopped the medicines advised by the neurologist, he became weak. He became so careless with money matters. He went to NIMHANS and consulted the doctors there. He was admitted there, but he could not cope with conditions there then he stopped medication. So he returned home and consulted another psychiatrist at Calicut. He started the habit of drinking alcoholic stimulants. Once he had made fights with
somebody in a Pooram. Again he had been taken to NIMHANS and returned without completing the course of the treatment. His restlessness and other complaints did not subside. Then he had admitted for further treatment.
HISTORY OF PAST ILLNESS
No history of psychiatric illness, epilepsy, and mental retardation.
FAMILY HISTORY
65 years years
Psychiatric illness
32 years 29 years
Index patent is youngest one in his family , History of psychiatric illness reported with Mother Maternal grandmother (episodic illness - mania) No history of mental retardation, epilepsy, suicide among other family members.
PERSONAL HISTORY
Normal home delivery. No prenatal complaints were reported. After the delivery, the
mother has been admitted with some psychiatric illness (puerperal mania?)
EDUCATIONAL HISTORY
He studied up to BA Economics degree. He was co-operative with peer group.
OCCUPATIONAL HISTORY
He was a parallel college teacher. He had his own institution.
SEXUAL HISTORY
Primary and secondary sexual characters were normal. He had positive attitudes
towards sex.
MEMORY
Immediate- Present. ( Digit forward test ,) Recent- Present. (Recollecting recent event ) Remote- Present. (Recollecting past event )
INTELLEGENCE Average General knowledge- Average. Abstract Thinking- Intact (proverb test) INSIGHT Awareness of illness-present Awareness of mentally ill- present Willingness to take treatment-present JUDGEMENT Personal- Present Social- Present. True emotional insight (grade – 6) VOLITION Present
PSYCHOLOGICAL ASSESSMENT Beck Depression Inventory- score is 18(moderate depression) SUMMARY AND DIAGNOSTIC FORMULATION
The patient is 29 years old year, unmarried male. The presenting complaints were swelling in the abdomen , pain in the abdomen mood off, suicidal thoughts, and irritability. The complaints started 4 ½ years back. He had a swelling in the abdomen and pain in the abdomen. He underwent endoscopy. He had difficulty in breathing while sleeping in the night. He became irritable and restless while taking classes in the college. His personal history all are normal and there is two significant psychiatric history in family, mother and Maternal grandmother mental illness (Mania) , pre morbidly well-adjusted and sociable. Mental statues examination showing presence of suicidal thought and anxious mood, rest of all mental function are normal. The Beck Depression Inventory has a score showing moderate depression (score -18).
DIAGNOSIS
Clinical feathers of patent meeting the DSM-IV-TR and ICD- 10 Diagnostic Criteria for Somatization Disorder with Psychiatric Symptoms. ( A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning, and The symptoms are not intentionally produced or feigned (as in factitious disorder or malingering).
MANAGEMENT
Psychotherapy and Pharmacotherapy
Somatization disorder is best treated when the patient has a single identified physician as primary caretaker. When more than one clinician is involved, patients have increased opportunities to express somatic complaints. Primary physicians should see patients during regularly scheduled visits, usually at monthly intervals. The visits should be relatively brief, although a partial physical examination should be conducted to respond to each new somatic complaint. Additional laboratory and diagnostic procedures should generally be avoided. Once somatization disorder has been diagnosed, the treating physician should listen to the somatic complaints as emotional expressions rather than as medical complaints. In psychotherapy settings, patients are helped to cope with their symptoms, to express underlying emotions, and to develop alternative strategies for expressing their feelings is very effective for somatization disorder, Pharmacological treatment is effective in patients without coexisting mental disorders, anti-depressant and benzodiazepines can be given on a short term basis for associated depression and anxiety. It mainly consists of; psychotherapy of somatization disorder mainly consisting Supportive psychotherapy Behavioral modification Relaxation therapy
MADE OF ONSET : acute CAUSE OF ILLNESS : Episodic (3 )rd
DURATION OF ILLNESS : Since 6 yrs old.
HISTORY OF PRESENT ILLNESS
The first episodic was started after death of his father. He was very much attached to father. Then onwards he has been showing some abnormal behaviours. Since that period onwards he was under psychiatric treatment. His illness is found as episodic. This is third episode. Before one week he was experiencing lack of sleep and poor apparition. He started to speak more. Whenever he talks over, stress violent behaviour will start. This time he is aggressive and destructive and abusive to family members. His was in asymptomatic in last one year, and one month before he stopped his medication.
NEGATIVE HISTORY:
No history suggestive of head injury, substance abuse and mental retardation.
TREATMENT HISTORY
2003 onwards the patient is under psychiatric treatment. He was taking mood stabilizers and other psychotic drugs. He was regular in medications till last one month, one month before he stopped medication.
PERSONAL HISTORY
BIRTH ANDE ARLY DEVELOPMENT: Prenatal, per natal and postnatal developments are reported as normal. PRESENCE OF CHILDHOOD DISORDERS : Nil
EDUCATIONAL HISTORY: Patient started his formal education when he was five year old and he stopped his studies after 10 thstandard. He had lots of friends.
OCCUPATIONAL HISTORY He is working in company as a driver at Dubai. :
PRE-MOBILE PERSONALIT : Patient was sociable. He had very good interpersonal relationships.
FAMILY HISTORY:
68 years 60 years,
47 years 40 yr 37yr 33yr
Index patent is eldest one his family ,there is no History of psychiatric illness reported in family and no history of mental retardation, epilepsy, suicide among other family members.
HOME ATMOSPHERE IN CHILDHOOD AND ADOLESCENCE: He had good home atmosphere. He was very attached to his father. PRESENT LIVING CONDITION : The patient is with his family. They are well in financially. ATTITUDE OF FAMILY: Family members are loving, caring and cooperative to the patient.
MENTAL STATUS EXAMINATION
JUDGMENT:
Test : satisfactory Social : Satisfactory Personal : Satisfactory
INSIGHT : Absent( complete denial- grade -1)
DIAGNOSTIC FORMULATION:
The patient is brought to the OPD with the complaints of lack of sleep, poor appetite, irritability, over activity, talkativeness and over religious activity. His MSE also shows that he was accelerated psychomotor activity, grandiose ideas, religiosity and flight of ideas. The illness is found as episodic. Base on ICD-10 criteria F31.1 the above mentioned symptoms show that the patient is affected by bipolar affective disorder, current episodic mania. ( DSM- IV TR:- A-Currently (or most recently) in a manic episode. B-There has previously been at least one major depressive episode, manic episode, or mixed episode. C-The mood episodes in Criteria A and B are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified)
TREATMENT PLAN Treatment of patients with mood disorders should be directed toward several goals. First, the patient's safety must be guaranteed. Second, a complete diagnostic evaluation of the patient is necessary. Third, a treatment plan that addresses not only the immediate symptoms but also the patient's prospective well-being should be initiated. Although current treatment emphasizes pharmacotherapy and psychotherapy addressed to the individual patient, stressful life events are also associated with increases in relapse rates. Thus, treatment should address the number and severity of stressors in patients' lives. Overall, the treatment of mood disorders is rewarding for psychiatrists.. Because the prognosis for each episode is good, optimism is always warranted and is welcomed by both the patient and the patient's family. Mood disorders are chronic, however, and the psychiatrist and psychologist must educate the patient and the family about future treatment strategies. The primary method of treatment for bipolar disorder is pharmacological intervention -
medications. The prescriptions for treatment are usually specific to mania or depression. Mood stabilizers are one of the most important groups of medications for bipolar disorder. Lithium was the first medication used to treat bipolar disorder, and it also can be used as an add-on treatment for clinical depression. in addition with lithium other druge such as Olanzapine (Zyprexa)Risperidone (Risperdal)Clozapine (Clozaril) also using the treatment of bipolar disorder. Psychotherapy is often recommended for people taking mood-stabilizing drugs, mostly to help them take their treatment as directed. Group therapy often helps people and their partners or relatives understand bipolar disorder and its effects. Individual psychotherapy may help people learn how to better cope with problems of daily living.
DURATION OF ILLNESS : 29years.
HISTORY OF PRESENT ILLNESS
Patient had the problems in sleep. Increased talk, restlessness, aggressive behaviour, excessive substance abuse, irritability etc. He also complaint about hearing voices which is like people talking about him.
Since 15 years of age, the patient was very disturbed and showed many abnormal behaviours. He had sleep problems, increased amount of talk and that too about unrelated things. He behave aggressively and destroyed many things. He was very stressed and lonely of the time and he extorted the area of substance abuse. He complained of having voices of people talking about him, There is no negative history( head injury, substance epilepsy or MR). He had the history of substance abuse. Since 16 thage onwards the patient was in psychiatric treatment. The patient had consulted many psychiatrists..
TREATMENT HISTORY:
Since 16 thage onwards the patient was psychiatric treatment. The patient had consulted many psychiatrists. And he irregular in medication and drug complaint
PERSONAL HISTORY:
Patent’s Birth and early development are normal
EDUCATIONAL HISTORY:
Formal education started in his 5 th^ age. He was poor was be. He stopped studies in 10th standard and started business.
OCCUPATIONAL HISTORY;
The patient is working since his 15 thage. He was helping his father in business.
PRE-MORBID PERSONALITY:
The patient was poor in social relations. He had the history of substance abuse.
FAMILY HISTORY:
Family Tree:
68 years 60 years,
46 years 44 yr 39yr 35yr
Index patent is second child in his family and belongs to financially lower class family, He living with family members, .They are cooperative and loving. There is no History of psychiatric illness reported in family and no history of mental retardation, epilepsy, suicide among other family members.
MENTAL SATUS EXAMINATION.
GENERAL APPEARANCE:
Well dressed, personal cleanliness is good. Body posture is appropriate, eye contact is sustained. Attitude towards examiner is cooperative. Report is established. PMA is normal.
SPEECH AND SOUND : Audible, normal reaction time but not good oriented.
MOOD AND AFFECT:
Subjective mood : “ I feel happy”.
Objective mood : Restricted.
PERCEPTUAL DISTURBANCES:
