SUMMER INTERNSHIP

(REPORT SUBMITTED FOR THE PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE
DEGREE OF MASTER OF ARTS IN CLINICAL PSYCHOLOGY)

AMITY INSTITUTE OF BEHAVIOURAL AND ALLIED SCIENCES

AMITY UNIVERSITY UTTAR PRADESH

LUCKNOW

SUBMITTED BY

TANYA KESARWANI

M.A. Clinical Psychology

Semester III

Enrollment No. A7403422025

UNDER THE GUIDANCE OF

DR. CHHAYA GUPTA

ASSISTANT PROFESSOR

AIBAS

Amity University Uttar Pradesh

Lucknow

2022-2024
 ACKNOWLEDGEMENT

I express my gratitude towards the director of Amity Institute of Behavioral and Allied Sciences, Prof.
S.Z.H. Zaidi for providing an opportunity to work on this SUMMER INTERNSHIP. I thank Ms. Garima
Singh and their Team for cooperating and letting us gain our learning experience. I would also extend my
thankfulness to the internal supervisors - Dr. Chhaya Gupta for their guidance, support and expertise
during this study.

- Tanya Kesarwani
 DECLARATION

I, hereby, declare that the paper entitled “SUMMER INTERNSHIP” is being submitted, to Amity
Institute of Behavioural and Allied Sciences, Amity University Uttar Pradesh, Lucknow, for the
award of the degree of ‘Master of Arts in Clinical Psychology’.

__________________________

Tanya Kesarwani

Enrollment No. : A7403422025

 CONTENTS

1. About the Organization Page 1

2. General Observation Page 2-13

3. Specific Observation Page 14

4. Case Study 1 Page 14

5. Case Study 2 Page 14

ABOUT THE ORGANISATION

INDIAN MENTAL HEALTH AND RESEARCH CENTRE (IMHRC) IS A UNIT OF IPYF
(REGISTERED UNDER INDIAN TRUSTS ACT, 1882) DEALING WITH PSYCHOLOGICAL AND
BEHAVIORAL ISSUES OF CHILDREN, ADOLESCENTS, ADULTS AND GERIATRIC
POPULATION. IT IS A CONTINUOUSLY GROWING ORGANIZATION, ONE OF ITS OWN KIND,
AIMING AT HELPING INDIVIDUALS LEAD A HAPPY, MEANINGFUL PROBLEM FREE LIFE.
IT IS BASED ON THE CONCEPT OF HOLISTIC HEALTH AIMING AT A HEALTHY MIND,
BODY AND SOUL.
IMHRC IS RUN BY SPECIALIZED TEAM COMPRISING PSYCHIATRISTS, RCI LICENSED
CLINICAL PSYCHOLOGISTS, COUNSELING PSYCHOLOGISTS AND EDUCATIONISTS.

IMHRC IS AUTHORIZED ACADEMIC PARTNER OF SIKKIM SKILL UNIVERSITY AND HAS

ACADEMIC COLLABORATION WITH SINGHANIA UNIVERSITY, COMMITTED TOWARDS
IMPARTING AND DISSEMINATING QUALITY EDUCATION, TRAINING AND RESEARCH IN
THE MENTAL HEALTHCARE & REHABILITATION SECTOR.

IMHRC LUCKNOW, DELIVERS MEDICAL AND REHABILITATIVE CARE FOR MENTAL AND
BEHAVIORAL PROBLEMS, PARTICULARLY DRUG ABUSE DISORDERS, PSYCHOTIC
DISORDERS, SCHIZOPHRENIA, DEPRESSION, AND ANXIETY. IT IS AFFILIATED WITH
NISCHAY HOSPITAL DE-ADDICTION AND REHABILITATION CENTER, LUCKNOW. THE
CENTER ALSO TREATS ILLNESSES LIKE EPILEPSY, EATING DISORDERS, BIPOLAR
DISORDER, PERSONALITY DISORDERS, DEMENTIA, AND BIPOLAR DISORDER.

THE HOSPITAL HAS TWO DEPARTMENTS: OP AND IP, EACH WITH 50 BEDS AND BASIC
AMENITIES FOR PATIENTS. DOCTORS SAURABH JAISWAL AND DR. FAUZIYA, MENTAL
HEALTH SPECIALISTS, AND OTHER TEAM MEMBERS WITH EXTENSIVE EXPERIENCE
OFFER PATIENTS IN NEED FULL SUPERVISION AND CARE.

SERVICES AND THERAPY PROVIDED AT THE CENTER

1. ALCOHOL DE DDICTION TREATMENT

2. DUAL DIAGNOSIS TREATMENT
3. ADDICTION TREATMENT
4. DETOX TREATMENT
5. INDIVIDUAL PSYCHOTHERAPY
6. COUPLES THERAPY
7. FAMILY THERAPY
8. SEX THERAPY
9. COUNSELLING
 GENERAL OBSERVATION
IMHRC IS ASSOCIATED WITH NISCHAY HOSPITAL, PROVIDING TREATMENT,
REHABILITATION, PSYCHO-EDUCATION, THERAPY, AND COUNSELING FOR
INPATIENTS AND OUTPATIENTS. MOST OF THE INPATIENTS ADMITTED TO THE
CENTER WERE TREATED FOR SUBSTANCE ABUSE AND PSYCHOTIC DISORDERS.
THE CENTER COMBINES MEDICATION WITH THE USE OF DIFFERENT CLINICALLY
PROVEN TECHNIQUES SUCH AS MEDITATION, YOGA, EXERCISE, AND OTHER
ACTIVITIES FOR EFFECTIVE TREATMENT. WHEN A PATIENT GETS ADMITTED TO
THE HOSPITAL, A COMPLETE CASE HISTORY, MSE (MENTAL STATUS
EXAMINATION), ASSESSMENT, AND NECESSARY TESTS WILL BE CONDUCTED BY
THE CLINICAL PSYCHOLOGISTS AND PSYCHIATRIC NURSE UNDER THE
PRESCRIPTION OF THE DOCTOR. ACCORDINGLY, WE WILL BE DECIDING THE
TREATMENT AND MANAGEMENT PLAN FOR THE PATIENT.

GENERALLY, FOR A PATIENT, THE TREATMENT STARTS BY FOCUSING ON HIS OR

HER DAILY ROUTINES IN THE BEGINNING. ALL PATIENTS HAVE TO FOLLOW THE
DAILY ROUTINES AT THE HOSPITAL, WHICH IS AS FOLLOWS:

 WAKE UP IN THE MORNING - 6 30 AM

 EXERCISE AND YOGA SESSION
 BREAKFAST
 MEDICATION
 ACTIVITIES –WHICH IS SPECIALLY FOCUSED ON COGNITIVE FUNCTIONING
LIKE MEMORY, THOUGHT PROCESS AND ATTENTION. PARTICIPATING IN
ACTIVITIES GIVES LEISURE AND ENERGY FOR THE PATIENTS MENTALLY
AND PHYSICALLY.
 LUNCH
 MEDICATION
 JACOBSON’S PROGRESSIVE MUSCLE RELAXATION(JPMR) SESSION-
FOCUSES ON TIGHTENING AND RELAXING SPECIFIC MUSCLE GROUPS IN
SEQUENCE
 LEISURE TIME-PATIENTS CAN WATCH TV OR READ BOOKS AND TAKE
REST.
 TEA TIME
 COUNSELLING THERAPIES USED TO HAPPEN IN BETWEEN AS SCHEDULED
  DINNER
 BEDTIME

DOCTOR’S INDIVIDUAL INTERACTION AND FOLLOW UP USED TO HAPPEN TWICE

IN A WEEK. COUNSELORS CLINICAL PSYCHOLOGISTS, AND PSYCHIATRIC
NURSES WERE PRESENT AT ALL THE TIME TO OBSERVE AND MAKE SURE THE
PATIENT’S IMPROVEMENT AND PARTICIPATION IN DAILY ROUTINE. THEY
INTERACT WITH THE PATIENTS AND PROVIDE MEDICATION PRESCRIBED AND
CONDUCT ACTIVITIES AND JPMR SESSION AND COUNSELING.

SPECIFIC OBSERVATION

FIRST WEEK WAS FOCUSED ON RAPPORT BUILDING WITH THE PATIENTS,

CONDUCTING ACTIVITIES, YOGA, MEDITATION AND JPMR SESSIONS.

RAPPORT BUILDING : IN A CLINICAL SET UP BUILDING A POSITIVE AND

TRUSTFUL RELATIONSHIP BETWEEN THE CARE PROVIDER AND THE PATIENT IS
VERY IMPORTANT FOR ESSENTIAL AND SUCCESSFUL TREATMENT .IT CREATES A
SAFE AND SUPPORTIVE ENVIRONMENT IN WHICH THE CLIENT FEELS
COMFORTABLE EXPRESSING THEIR THOUGHTS, EMOTIONS, AND CONCERNS.

ACTIVITIES FOR PATIENTS: THE ACTIVITIES HAVE BEEN PLANNED AND

CONDUCTED ON PATIENTS LIKE DRAWING, MANDALA ART MAKING, WRITE
ABOUT YOURSELF ,WRITING ON SPECIFIC TOPICS SUCH AS SCHOOL DAYS, BEST
MEMORIES OF YOUR LIFE AND PLAYING MUSICAL CHAIR ,ETC. THE ACTIVITIES
WERE CONDUCTING TO OBSERVE THE PARTICIPATION OF PATIENTS
PHYSICALLY AND MENTALLY AND FOCUSING ON THE COGNITIVE ORIENTATION
OF THE PATIENT SUCH AS MEMORY, ATTENTION, THOUGHT PROCESS ETC.

MEDITATION AND YOGA: MEDITATION AND YOGA CAN HELP IN EMOTIONAL,

PSYCHOLOGICAL AND PHYSICAL WELLBEING OF THE PATIENT .IT HELPS TO REDUCE
ANXIETY, TENSION AND RELAX THE BODY AND MIND. THE YOGA SESSIONS WERE
CONDUCTING BEFORE BREAKFAST WHICH MAINLY FOCUSING ON BREATH-FOCUSED
YOGA CALLED PRANAYAMA COMMONLY ANULOMVILOM (ALTERNATE NOSTRIL
BREATHING), NADISHODHANA (ALTERNATE NOSTRIL BREATHING) AND OM
CHANTING.
WEEK 2 SESSIONS WERE THE FOLLOW UP OF THE FIRST WEEK SESSIONS AND
ALSO LEARNING ABOUT DETAILED CASE HISTORY FORMAT , MENTAL STATUS
EXAMINATION , PROVISIONAL DIAGNOSIS USING ICD 10 AND ALSO COMMON
DISORDERS WERE BEING TREATED AT THE CENTER.

CASE HISTORY

HISTORY TAKING IN A PSYCHIATRY AND PSYCHOLOGY IS IMPORTANT AS IT

HELPS OBTAINING BETTER INFORMATION, MAKING A MORE ACCURATE
DIAGNOSIS, ESTABLISHING A BETTER RAPPORT WITH PATIENTS AND WORKING
TOWARDS BETTER ADHERENCE WITH MANAGEMENT PLAN. IT WAS OBSERVED
AND ALSO DONE DETAILED SOCIO-DEMOGRAPHIC DATA AND HISTORY OF
PRESENT ILLNESS WHICH IS BEING TAKEN DURING THE INTERNSHIP WHICH
HELPED TO IMPROVE QUESTIONING SKILLS, RAPPORT BUILDING AND
PROVISIONAL DIAGNOSIS .

MENTAL STATUS EXAMINATION

MSE HELPS TO UNDERSTAND THE CURRENT FUNCTIONING OF COGNITIVE

ABILITIES OF THE PATIENT. IT IS BEEN OBSERVED AND TAUGHT STANDARDIZED
FORMAT OF MSE IN ALL AREAS OF MENTAL FUNCTIONING .

PROVISIONAL DIAGNOSIS USING ICD 10

BASED ON THE DETAILED CASE HISTORY PROVISIONAL DIAGNOSIS BEEN DONE USING
ICD 10.WHEN A PATIENT PRESENTS WITH SYMPTOMS, A HEALTHCARE PROFESSIONAL
MAY USE ICD-10 CODES AS PART OF THE PROVISIONAL DIAGNOSIS PROCESS.A
PROVISIONAL DIAGNOSIS IS A TEMPORARY OR PRELIMINARY DIAGNOSIS MADE BY A
HEALTHCARE PROFESSIONAL BASED ON THE PATIENT'S SYMPTOMS, MEDICAL HISTORY,
AND INITIAL EXAMINATION.

COMMON DISORDERS OBSERVED AT THE CENTER WERE

1. MENTAL AND BEHAVIOURAL DISORDERS DUE TO PSYCHOACTIVE

SUBSTANCE USE: ALSO KNOWN AS SUBSTANCE-INDUCED DISORDERS, ARE
A GROUP OF CONDITIONS THAT ARISE AS A RESULT OF THE USE OR
WITHDRAWAL OF PSYCHOACTIVE SUBSTANCES. THESE SUBSTANCES CAN
INCLUDE ALCOHOL, DRUGS (BOTH ILLICIT AND PRESCRIPTION), AND
OTHER CHEMICAL SUBSTANCES THAT AFFECT THE CENTRAL NERVOUS
SYSTEM AND CAN LEAD TO CHANGES IN BEHAVIOUR, MOOD, COGNITION,
AND PERCEPTION. IT IS BEEN OBSERVED SUBSTANCE ABUSE CASES MANY
 AT THE CENTRE AND COULD OBSERVE AND WITHDRAWAL STATE
SYMPTOMS AND COMORBID CONDITIONS OF THE SAME
2. PSYCHOTIC DISORDERS:IT IS A GROUP OF SEVERE MENTAL HEALTH
CONDITIONS CHARACTERIZED BY A LOSS OF TOUCH WITH REALITY,
OFTEN LEADING TO HALLUCINATIONS, DELUSIONS, DISORGANIZED
THINKING, AND ABNORMAL BEHAVIOUR. SCHIZOPHRENIA, ACUTE
PSYCHOTIC DISORDERS AND DELUSIONAL DISORDERS WERE OBSERVED
IN PATIENTS AT THE CENTRE .DURING THE HISTORY TAKING COULD ALSO
BEEN OBSERVED THAT PATIENTS ARE ALSO HAVING THE SYMPTOMS OF
DEPRESSION AND ANXIETY .

A DETAILED CASE HISTORY , MENTAL STATUS EXAMINATION ,AND DAILY

ACTIVITIES BEEN CONDUCTED DURING THE THIRD WEEK.

IT IS BEEN OBSERVED AND PRACTICED VARIOUS ASSESSMENTS AND TESTS

DURING THE FOURTH WEEK AS FOLLOWS

AUDIT

AUDIT (ALCOHOL USE DISORDERS IDENTIFICATION TEST) IS A COMPREHENSIVE

10 QUESTION ALCOHOL HARM SCREENING TOOL.IT WAS DEVELOPED BY THE
WHO(WORLD HEALTH ORGANIZATION ) AND BEEN USED IN A VARIETY OF
HEALTH AND SOCIAL CARE SETTINGS. IF THE PATIENT HAS BEEN CONSUMED
ONLY ALCOHOL THEN WE USE AUDIT TO SCORE AND GIVE FEEDBACK TO THE
PATIENT ABOUT THE RATE OR RISK INVOLVED IN HIS ALCOHOL CONSUMPTION.

ASSIST

ASSIST( ALCOHOL,SMOKING, AND SUBSTANCE INVOLVEMENT SCREENING TEST)

DEVELOPED BY WHO INCLUDES A SERIES OF QUESTIONNAIRE THAT SCREENS
ALL LEVELS OF RISKS INCLUDES IN SUBSTANCE USE IN ADULTS. WHEN THE
PATIENT IS HAS MULTIPLE DRUG USED ASSIST USED TO CONDUCT TO EXPLAIN
THE RISK FACTORS ASSOCIATED WITH PATIENT’S DRUG USE.

BPRS

BPRS(BRIEF PSYCHIATRIC RATING SCALE)USED TO MEASURE THE PATIENT’S

ANXIETY, DEPRESSION, AND PSYCHOSES .THIS TOOL BEEN USED WHEN THE
PATIENT PRESENT WITH THE SYMPTOMS OF ANXIETY, PSYCHOSES AND
DEPRESSION.

HAMILTON ANXIETY RATING SCALE-A

HAM-A WAS ONE OF THE FIRST SCALES DEVELOPED TO MEASURE THE SEVERITY
OF ANXIETY SYMPTOMS AND STILL WIDELY USED TODAY. ACCORDING TO THE
SCORING THE SEVERITY LEVEL OF PATIENT BEEN RULED OUT.

ALSO USED BECK ANXIETY INVENTORY (BAI) ,HAMILTON DEPRESSION

RATING SCALE (HAM-D) ALSO USED AS ASSESSMENT TOOLS DURING
INTERVENTION

ALSO GOT FAMILIAR WITH THE TEST SACK’S SENTENCE TEST AND HUMAN
FIGURE DRAWING TEST (HFDT)- THE PROJECTIVE ASSESSMENT TOOL TO ELICIT
THE PATIENT’S OVERALL PERSONALITY ,FEELINGS, CONFLICTS AND
COGNITION.
 CASE STUDY I

IDENTIFICATION DATA
NAME: MR. A.T
AGE: 31YEARS
GENDER: MALE
EDUCATIONAL QUALIFICATIONS: B.COM
OCCUPATION: WORKED AT BUYJU’S
MARITAL STATUS: MARRIED
SOCIO-ECONOMIC STATUS: MIDDLE CLASS
ADDRESS GOMTI NAGAR
PLACE OF RESIDENCE: URBAN
NATIONALITY INDIAN
LANGUAGE HINDI AND ENGLISH
INFORMANTS: PATIENT
RELIABILITY AND ADEQUACY Of : NOT RELIABLE AND INADEQUATE
INFORMATION

PRESENTING COMPLAINTS (FROM PATIENT)

ALCOHOL LETE THE
FAMILY ISSUES HAI
WIFE KE SATH DHAKA MUKKI HUI THI
FAMILY MISUNDERSTANDINGS BHUT HAI
STRESS LAGATAR RHETA THA
ANGER ISSUES HAI
MAI EGOISTIC HU
CHIEF COMPLAINTS (WITH DURATION)
CONSUMTION OF ALCOHOL – B.COM 3RD YEAR
AGGRESSIVE BEHAVIOUR
STRESS

FAMILY CONFLICTS

INSOMNIA

MODE OF ONSET:INSIDIOUS
COURSE:EPISODIC
PROGRESS:IMPROVING

PREDISPOSING FACTOR: FAMILY HISTORY OF CONSUMPTION OF ALCOHOL

(FATHER& BROTHER)
PRECIPITATING FACTOR: STRAIN HOME ENVIRONMENT
PERPETUATING FACTOR: STRESS AND RESPONSIBILTY

HISTORY OF PRESENT ILLNESS:

ACCORDING TO THE INDEX PATIENT, MR A.T IS 31 YEARS OLD, WAS
MAINTAINING WELL UNTILL APRIL 2023 , HE’S BEING INTO DRINKING SINCE HIS
GRADUATION ON OCCASSIONAL BASIS AND LATER DUE TO FAMILY ISSUES,
RESPONSIBILITY OF THE HOUSE ON HIM, FAMILY CONFLICTS, AGGRESSIVE
BEHAVOUR, VIOLENT BEHAVIOUR AND STRESS HE STARTED CONSUMING
ALCOHOL. HE STARTED HAVING LACK OF SLEEP, HE USE TO DRINK IN 10-20
DAYS OF GAP AND MAJORLY DEPEND ON STRAIN HOME ENVIRONMENT.
HE HAS STABLE APPETITE. HIS WIFE HAS 2 MISCARRAIGES AND THE FATHER’S
AND ELDER BROTHER’S DEATH CAUSED HIM AND HIS FAMILY THE UNSTABLE
CONDITIONS.
IN APRIL 18,2013 HE WAS BROUGHT TO THE HOSPITAL AND WAS UNAWARE THAT
HE WAS IN THE HOSPITAL, A DAY BEFORE HE HAD BEEN INTO FIGHT WITH HIS
WIFE AND OTHER FAMILY MEMBERS DURING WHICH HE WAS BEING INTO
VIOLENT AND AGGRESSIVE BEHAVIOR.
HE HAD STRAIN HOME ENVIRONMENT, HIS WIFE AND HIS BROTHER’S WIFE ARE
INTO JOB. HE HAD CORDIAL RELATION WITH FRIENDS AND OTHER SOCIAL
SETTINGS.
TOTAL DURATION OF ILLNESS: 2YEARS
BIOLOGICAL FUNCTIONS:
SLEEP: DISTURBED
APPETITE: STABLE
NEGATIVE HISTORY:

 THERE IS NO HISTORY SUGGESTIVE OF BRAIN TRAUMA/INJURY


THERE IS NO HISTORY SUGGESTIVE OF HEARING OF VOICES NOT HEARED
BY OTHERS OR SEEING OBJECTS OR IMAGES NOT SEEN BY OTHERS

 THERE IS NO HISTORY SUGESSTIVE OF LOW MOOD AND ELVATED MOOD


THERE IS NO HISTORY SUGGESTIVE OF IRRATIONAL FEAR

TREATMENT HISTORY:
COULDN’T BE ELICITED

PAST HISTORY:
NIL CONTRIBUTORY
FAMILY HISTORY:
FATHER’S NAME – LATE UMA SHANKAR(DUE TO ORGAN DAMAGE)

MOTHER’S NAME – MRS DEVMAIT TRIPATHI(AGE 52YEARS) – GALL BLADDAR

OPERATION

WIFE’S NAME – MAMTA TRIPATHI – 2 MISCARRAIGES

ELDER BROTHER’S NAME – LATE AMIT TRIPATHI - MARRIED

YOUNGER BROTHER’S NAME – MR ANKIT TRIPATHI(AGE 29YEARS)

PRIMARY EARNING MEMBER - PATIENT, WIFE AND BROTHER’S WIFE

NO HISTORY OF MENTAL ILLNESS IN THE FAMILY AS REPORTED BY THE
PATIENT

PERSONAL HISTORY (TO BE PRESENTED UNDER FOLLOWING HEADINGS)

 DEVELOPMENTAL HISTORY (THIS HEADING WILL INCLUDE PRENATAL
HISTORY, BIRTH COMPLICATIONS, NATURE OF DELIVERY, DEVELOPMENTAL
MILESTONES ETC)
NO BIRTH COMPLICATION AND NORMAL DELIVERY AS REPORTED BY THE
PATIENT

 PRESENCE OF EARLY CHILDHOOD DISORDERS

COULBN’T BE ELICITED

 HOME ENVIRONMENT

CORDIAL BUT STRAIN AFTER THE DEATH OF HIS FATHER AND ELDER BROTHER

 SCHOLASTIC HISTORY (WILL ALSO INCLUDE PLAY BEHAVIOR)

ABOVE AVERAGE STUDENT

INTERESTED IN SPORTS LIKE CRICKET

 VOCATIONAL HISTORY
WORKED IN BUSINESS DEVELOPMENT ASSOCIATION
M.COM DROPPED
TRIED FOR MBA
WORKING IN BUYJU’S FOR 2 YEARS

 SEXUAL HISTORY

COULDN’T BE ELICITED

 LIVING CONDITIONS (WHO ALL IN FAMILY, ROOMS, INCOME, EARNING

MEMBERS ETC)

THE PATIENT HAS MOTHER AND 3 SIBLINGS, BELONGS TO A NUCLEAR FAMILY

AND THE PATIENT HIMSELF IS THE EARNING MEMBER IN THE FAMILY . AFTER
THE DEATH IN HIS FAMILY THERE WAS UNSTABLLE LIVING CONDITIONS

PREMORBID PERSONALITY:
 SELF- STABLE AND HAPPY, LOVING
 RELATION- CLOSE AND HAPPY RELATION WITH FRIENDS AND FAMILY
 WORK AND LEISURE- CURRENTLY DOING JOB AT BUYJU’S AND SPENT
TIME WITH FAMILY
 MOOD- HAPPY
 CHARACTER- SUSPICIOUS
 ATTITUDE- RESPECTFUL
 HABITS- DO WORK SYSTEMATICALLY

 HOBBIES – GAMES AND CRICKET

IMPRESSION: THE PATIENT WAS WELL-ADJUSTED AS HE ANWERED ALL THE
QUESTIONS. HE USE TO BE HAPPY, ENJOY MORE AND BEEN INTERESTED BEFORE
THE DEATH OF HIS FATHER AND BROTHER BUT LATER HE DEVELOP ANGER
ISSUES AND HAVE VIOLENT AND AGGRESSIVE BEHAVIOUR , AND WANTED TO
BE ALONE.

BEHAVIORAL OBSERVATION/MENTAL STATUS EXAMINATION

 GENERAL APPEARANCE AND BEHAVIOR: THE PATIENT WAS WELL KEPT

AND TIDY, DRESSED APPROPRIATELY, COOPERATIVE AND RAPPORT WAS
ESTABLISHED
 ATTITUDE AND RELATIONSHIP TO EXAMINER: THE PATIENT WAS
RESPECTFUL, MAINTAINED EYE CONTACT AND INTERESTED
 MOTOR BEHAVIOR:THE PATIENT HAD HAND MOVEMENT.
 SPEECH: THE PATIENT WAS AUDIBLE WITH CLEAR SPEECH AND WITH
LOW TO NORMAL RANGE OF PITCH

COGNITIVE FUNCTIONS
 ATTENTION AND CONCENTRATION: ATTENTION WAS AROUSED AND
SUSTAINED

 ORIENTATION

TIME - INTACT
PLACE - INTACT
PERSON - INTACT
  MEMORY

IMMEDIATE – INTACT(EXCEPT – 1 FORWARD)

RECENT - INTACT
REMOTE - INTACT

 THINKING ABILITY: CONCRETE

 GENERAL FUND OF INFORMATION: AVERAGE

 CALCULATIONS: THE PATIENT WAS ABLE TO SOLVE COMPLEX

MATHEMATICAL CALCULATIONS

INTELLIGENCE: ABOVE AVERAGE LEVEL OF INTELLECTUAL FUNCTIONING

AFFECT:

SUBJECTIVE-
AJEEB SA LAG RHA THA

OBJECTIVE-
ANXIOUS

THOUGHT – HELPLESSNESS

PERCEPTUAL DISORDERS: (HALLUCINATIONS AND ILLUSIONS)

NO ABNORMALITY DETECTED

JUDGMENT – TEST, SOCIAL, PERSONAL

THE PATIENT GAVE A SATISFACTORY ANSWERS IN ALL THE THREE DOMAIN

INSIGHT: GRADE V – INTELLECTUALL INSIGHT

PROVISIONAL DIAGNOSIS:
F19 – MENTAL AND BEHAVIOURAL DISORDERS DUE TO MULTIPLE DRUG USE
AND USE OF OTHER PSYCHOACTIVE SUBSTANCE
F19.26 DEPENDENCE SYNDROME- CURRENTLY ABSTINENT, BUT IN A PROTECTED
ENVIRONMENT

ASSESSMENTS ADMINISTERED
NAME OF THE
SL. NO. TEST RAW SCORE RATIONALE

HAMILTON
ANXIETY MILD LEVEL OF
1 15
RATING SCALE ANXIETY
(HAM - A)

2 ALCOHOL USE POSSIBLE

DISORDER
IDENTIFICATION 24 DEPENDENCE
TEST(AUDIT)

TEST BEHAVIOR:
THE PATIENT WAS COOPERATIVE AND RESPECTFUL YET HE HAD SHIVERING
LEGS, DISTRACTIVE BEHAVIOUR DURING THE CONDUCTION OF THE
ASSESSMENTS.

TEST FINDINGS:THE TEST FINDINGS ARE INDICATIVE OF SUBSTANCE USE

TENDENCIES.
IN HAM-A ,THE SYMPTOMS OF PSYCHIC ANXIETY(MENTAL AGITATION AND
DISTRESS) WAS EVIDENT FROM THE APPERENCE OF THE PATIENT. THE SCORE
OBTAINED WAS 15 WHICH IMPLIES THAT HE HAS MILD LEVEL OF ANXIETY.
IN AUDIT, THE PATIENT HAS POSSIBLE DEPENDENCE ON ALCOHOL WHICH
INDICATES THAT HE IS AT HIGH RISK OF EXPERIENCING SEVERE
PROBLEMS(HEALTH, SOCIAL, FINANCIAL, LEGAL, RELATIONSHIP) AS A RESULT
OF HIS CURRENT PATTERN OF SUBSTANCE USE.
IMPRESSION:
BASED ON CASE HISTORY, MENTAL STATUS EXAMINATION AND ASSESSMENT,
THE FINDINGS ARE INDICATIVE OF SUBSTANCE USE DISORDER COMORBID WITH
MILD LEVEL OF ANXIETY FEATURES.

EXAMINER SUPERVISOR

SIGNATURE SIGNATURE

DATE DATE
 CASE STUDY 2

IDENTIFICATION DATA
NAME: MR. A.V
AGE: 29YEARS
GENDER: MALE
EDUCATIONAL QUALIFICATIONS: GRADUATED
OCCUPATION: UNEMPOLYEED
MARITAL STATUS: UNMARRIED
SOCIO-ECONOMIC STATUS: MIDDLE CLASS
ADDRESS NEELMATHA, TOPKHANA, CANTT
PLACE OF RESIDENCE: URBAN
NATIONALITY INDIAN
LANGUAGE HINDI
INFORMANTS: PATIENT
RELIABILITY AND ADEQUACY Of : NOT RELIABLE AND INADEQUATE
INFORMATION

PRESENTING COMPLAINTS (FROM PATIENT)

GANJA PEETE THE OR CIGARETTE KABHI KABHI
KHANE KA BHUT MAN KRTA THA PINE KE BAAD
SEENE MAI JALAN HOTI HAI 4-5 DIN SE
PAPA SE HATHAPAYI HUI THI
PAPA DEKH KR AISA LAGTA THA KI VO EMOTIONAL BLACKMAIL KAR RHE HO
PHELE GUSSA BHUT AATA THA
ULJHAN HOTI HAI
HASTE RHETE HAI
BADHBADATE RHETE THE
HAMESHA CHALTE YA TAHELTE RHETE HAI
DEPRESSION MAI THE KYU KI SARKARI NAUKARI NAHI MIL RHI THI
GHAR WALO NE PAGAL KIYA HAI
AISA LAGA KI KOI MERE BAARE MAI BAAT KR RHA HO
MUJHE AWAZE SUNAI DETI THI

CHIEF COMPLAINTS (WITH DURATION)

CONSUMPTION OF CANNABIS AND TOBACCO
INCREASED APPETITE
FEELING OF BURNING OF CHEST – 4-5 DAYS
LOW MOOD
AGGRESSIVE BEHAVIOUR
LAUGHING RANDOMLY
MUMMURING
IRRITABILITY
WALKING AT RANDOM
HEARING OF VOICES NOT HEARD BY OTHERS
FELT LIKE SOMEONE ELSE IS TAKING ABOUT ME.

MODE OF ONSET:INSIDIOUS
COURSE:CONTINUOUS
PROGRESS:IMPROVING
 PREDISPOSING FACTOR: CONSUMPTION OF CIGARETE AND CANNABIS DUE
TO SOCIAL SETTING AND FAMILY MEMBERS(FATHER AND UNCLE)
PRECIPITATING FACTOR: PEER INFLUENCE AND FAMILY CONFLICT
PERPETUATING FACTOR: PEER INFLUENCE AND STRAIN HOME
ENVIRONMENT

HISTORY OF PRESENT ILLNESS:

ACCORDING TO THE INDEX PATIENT, MR A.V IS 29 YEARS OLD, WAS
MAINTAINING WELL UNTILL 2015 AFTER WHICH HE STARTED CONSUMING
CANNABIS AND TOBACCO DUE TO PEER INFLUENCE AND FAMILY AND ALSO
CONSUME ALCOHOL OCSASSIONALLY . HE WAS BROUGHT TO THE HOSPITAL IN
2016 FOR THE FIRST TIME IN NIRVAAN AND CURRENTLY IN NISCHAY HOSPITAL
AS HE WAS HAVING ANGER ISSUES, INCREASED IN APPETITE, RANDOMLY
LAUGHING, MUMMURING, IRRITABILITY, FELT BURNING IN THE CHEST,
WALKING AT RANDOM, HEARING OF VOICES NOT HEARD BY OTHERS AND FELT
LIKE SOMEONE ELSE ID TAKING ABOUT ME.
HE HAD STRAIN RELATION WITH HIS FATHER AS WELL AS HAS STRAIN HOME
ENVIRONMENT AS HIS ELDER SISTER DIED DUE TO PNEUMONIA AND WAS
PARALYZED, HIS MOTHER DIED IN COVID. HE HAD CORDIAL RELATION WITH HIS
FRIENDS.
HE FIRST STARTED WITH THE CONSUMPTION OF TOBACCO IN CLASS 11-12 TH,
THEN CONSUMPTION OF CANNABIS, BEING GRADUATED IN 2015, HAD NO JOB,
CONFLICT WITH FATHER. RESTRICTION FOR THE STUDIES AND JOB AND FELT
FUSTRATED HAVING NOTHING IN HAND.
HE IS BEING AWARE OF THE FACT THAT HE HAS BEEN ADMITTED TO MORE
THAN ONE HOSPITAL AND CURRENTLY IN APRIL CAME TO THE CENTRE. HE IS
BEEN AWARE ABOUT HIS FAMILY MEMBERS, THEIR CONFLICTS AMONG
THEMSELVES. THE LAST CONSUMPTION OF CANNABIS WAS IN 2018-19. HE USE TO
DRINK OCCASIONALLY.

TOTAL DURATION OF ILLNESS: 8YEARS

BIOLOGICAL FUNCTIONS:
SLEEP: STABLE
APPETITE: INCREASED
NEGATIVE HISTORY:

 THERE IS NO HISTORY SUGGESTIVE OF BRAIN TRAUMA/INJURY


THERE IS NO HISTORY SUGGESTIVE OF IRRATIONAL FEAR

 THERE IS NO HISTORY SUGGESTIVE OF ELEVATED MOOD


THERE IS NO HISTORY SUGGESTIVE OF SUICIDAL IDEATION

TREATMENT HISTORY:
NIRVAAN – 2016

DARPAN

NISHCHAY HOSPITAL

SANDEEP NATURAL PATHY

JEEVAN JOYTI

PAST HISTORY:
CONSUMPTION OF CANNABIS AND TOBACCO
DEPRESSION
ANGER ISSUES

IRRITIBLITY

FAMILY HISTORY:
FATHER’S NAME – MR SURESH KUMAR VERMA(AGE 82YEARS)

MOTHER’S NAME – LATE MANJULA VERMA

ELDER SISTER’S NAME – LATE SITU VERMA

YOUNGER BROTHER’S NAME – MR PIYUSH VERMA(AGE 28YEARS) - JOB

PRIMARY EARNING MEMBER - FATHER AND BROTHER

THERE IS HISTORY OF MENTAL ILLNESS IN THE FAMILY AS REPORTED BY THE

PATIENT – FATHER’S BROTHER’S DAUGHTER

PERSONAL HISTORY (TO BE PRESENTED UNDER FOLLOWING HEADINGS)

 DEVELOPMENTAL HISTORY (THIS HEADING WILL INCLUDE PRENATAL
HISTORY, BIRTH COMPLICATIONS, NATURE OF DELIVERY, DEVELOPMENTAL
MILESTONES ETC)
NO BIRTH COMPLICATION AND NORMAL DELIVERY AS REPORTED BY THE
PATIENT

 PRESENCE OF EARLY CHILDHOOD DISORDERS

COULBN’T BE ELICITED

 HOME ENVIRONMENT

STRAIN – DUE TO CONSUMPTION OF ALCOHOL OCCASIONALLY BY FATHER AND

UNCLE WAS A REGULER DRINKER AND ALSO USE OF ABUSIVE LANGUAGE IN
THE HOUSE

 SCHOLASTIC HISTORY (WILL ALSO INCLUDE PLAY BEHAVIOR)

AVERAGE STUDENT

INTERESTED IN SPORTS LIKE CRICKET

 VOCATIONAL HISTORY
UNEMPOLYEED

 SEXUAL HISTORY

NIL CONTRIBUTORY

 LIVING CONDITIONS (WHO ALL IN FAMILY, ROOMS, INCOME, EARNING

MEMBERS ETC)

THE PATIENT HAS FATHER, AND 1 SIBLINGS, BELONGS TO A JOINT FAMILY AND
HIS FATHER AND BROTHER ARE THE EARNING MEMBER IN THE FAMILY
PREMORBID PERSONALITY:
 SELF- STABLE AND HAPPY
 RELATION- CLOSE AND HAPPY RELATION WITH FRIENDS BUT STRAIN
HOME ENVIRONMENT
 WORK AND LEISURE- FUN TIME WITH FRIENDS
 MOOD- HAPPY
 CHARACTER- KIND
 ATTITUDE- RESPECTFUL
 HABITS- PLAYING GAMES AND DRINK

 HOBBIES – TRAVELLING, CRICKET AND PLAYING GAMES

IMPRESSION: THE PATIENT WAS WELL-ADJUSTED AS HE ANWERED ALL THE
QUESTIONS. HE USE TO BE HAPPY, ENJOY MORE AND BEEN INTERESTED BEFORE
THE CONSUMPTION OF CANNABIS AND TOBACCO BUT LATER HE DEVELOP
ANGER ISSUES AND DISTURBANCE IN HIS BEHAVIOUR.

BEHAVIORAL OBSERVATION/MENTAL STATUS EXAMINATION

 GENERAL APPEARANCE AND BEHAVIOR: THE PATIENT WAS WELL KEPT

AND TIDY, DRESSED APPROPRIATELY, COOPERATIVE AND RAPPORT WAS
ESTABLISHED
 ATTITUDE AND RELATIONSHIP TO EXAMINER: THE PATIENT WAS
RESPECTFUL, PARTIAL EYE CONTACT AND INTERESTED
 MOTOR BEHAVIOR:THE PATIENT HAD FIDGETING BODY MOVEMENT
WITH DISTRACTIVE BEHAVIOUR.
 SPEECH: THE PATIENT WAS AUDIBLE WITH CLEAR SPEECH AND WITH
LOW TO NORMAL RANGE OF PITCH

COGNITIVE FUNCTIONS
 ATTENTION AND CONCENTRATION: ATTENTION WAS AROUSED AND
SUSTAINED

 ORIENTATION

TIME - INTACT
PLACE - INTACT
PERSON - INTACT

 MEMORY

IMMEDIATE – INTACT(EXCEPT – 1 FORWARD AND 1 BACKWARD)

RECENT - INTACT
 REMOTE - INTACT

 THINKING ABILITY: FUNCTIONAL

 GENERAL FUND OF INFORMATION: AVERAGE

 CALCULATIONS: THE PATIENT WAS ABLE TO SOLVE SIMPLE
MATHEMATICAL CALCULATIONS

INTELLIGENCE: BELOW AVERAGE LEVEL OF INTELLECTUAL FUNCTIONING

AFFECT:

SUBJECTIVE-
ULJHAAN HOTI HAI
OBJECTIVE-
ANXIOUS

THOUGHT – HELPLESSNESS AND HOPELESSNESS

PERCEPTUAL DISORDERS: (HALLUCINATIONS AND ILLUSIONS)

AUDITORY HALLUCINATION WAS DETECTED

JUDGMENT – TEST, SOCIAL, PERSONAL

THE PATIENT GAVE A SATISFACTORY ANSWERS IN ALL THE THREE DOMAIN

INSIGHT: GRADE III – AWARENESS OF BEING SICK BUT BLAMING TO EXTERNAL

FACTOR

PROVISIONAL DIAGNOSIS:
F19 – MENTAL AND BEHAVIOURAL DISORDERS DUE TO MULTIPLE DRUG USE
AND USE OF OTHER PSYCHOACTIVE SUBSTANCE
F19.26 DEPENDENCE SYNDROME- CURRENTLY ABSTINENT, BUT IN A PROTECTED
ENVIRONMENT

ASSESSMENTS ADMINISTERED
NAME OF THE
SL. NO. TEST RAW SCORE RATIONALE

BRIEF
PSYCHIATRIC MODERATELY
1 68
RATING SCALE SEVERE
(BPRS)

PSYCHOTIC
2 HUMAN FIGURE TENDENCIES
DRAWING WITH
TEST(HFDT) DEPRESSIVE
FEATURES

TEST BEHAVIOR:
THE PATIENT WAS COOPERATIVE AND RESPECTFUL YET HE HAD SHIVERING
LEGS, DISTRACTIVE AND FIDGETING WHILE THE CONDUCTION OF THE
ASSESSMENTS.

TEST FINDINGS:THE TEST FINDINGS ARE INDICATIVE OF PSYCHOTIC

TENDENCIES.
IN BPRS - THE SCORE OBTAINED BY THE PATIENT WAS 68 WHICH IMPLIES THAT
HE HAS MODERATELY SEVERE LEVEL OF PSYCHOTIC SYMPTOMS.

IN HFDT - LARGE DOMINANT MALE DRAWN BY MALE IS INDICATIVE OF SELF-

INFLATION AND BELITTLING ATTITUDE TOWARDS FEMALES; IT CAN ALSO BE
REFLECTIVE OF POSSIBLE DEPRESSION. BOTTOM PLACEMENT ALONG WITH
OMIISION OF FINGERS IS SUGGESTIVE OF FEELINGS OF INTERPERSONAL
INADEQUACY AND INFERIORITY. LEFT PLACEMENT IS INDICATIVE OF
UNCERTAINITY, APPREHENSIVENESS, AND CONCERN WITH PAST EVENTS. GROSS
DISPROPORTION AS WELL AS TRANSPARENCIES IN THE FIGURE IS INDICATIVE
OF IMPAIRMENT IN REALITY TESTING. FIGURE WITH A BLANK OUTLINE IS
SUGGESTIVE OF EMOTIONAL WITHDRAWAL, POOR INSIGHT AS WELL AS POOR
REASONING ABILITY. DISPLAY OF INTERNAL ORGAN IS REFLECTIVE OF
SOMATIC CONCERNS AND INTERNAL PATHOLOGY. LIGHT LINES ALONG WITH
OMISSION OF HANDS IS INDICATIVE OF GENERALISED ANXIETY AND
DEPRESSIVE TENDENCIES ALONG WITH TIMIDNESS AND POOR SELF CONCEPT.
NAKED FIGURE WITH GENITALIA IS INDICATIVE OF GRAPHOMOTOR
DIFFICULTIES, SEXUAL CONFLICTS, AND/OR REGRESSION. OMISSION OF EYES IN
THE FIGURE IS INDICATIVE OF VOYEURISTIC TENDENCIES, INEFFECTIVENESS,
AND VISUAL HALLUCINATIONS. OMISSION OF MOUTH AS WELL AS ARMS IS
INDICATIVE OF ORAL DEPENDENCY, NEED FOR AFFECTION, GUILT, AND
SUSPICION. OMISSION OF LEGS AND FEET HAS BEEN ASSOCIATED WITH
PROBLEMS WITH PSYCHOLOGICAL MOBILITY, POSSIBLE DEPENDENCE, AND
COGNITIVE DYSFUNCTION. STEREOTYPED FIGURE IS INDICATIVE OF FANTASY
PROJECTION OF THE SELF, EITHER SELF-AGGRANDIZING OR SELF-DEPRECATING.

OVERALL FINDINGS ARE SUGGESTIVE OF IMPAIRMENT IN REALITY TESTING,

DEPRESSIVE TENDENCIES, GENERALIZED ANXIETY, EMOTIONAL WITHDRAWAL,
POOR SELF-CONCEPT, POSSIBLE DEPENDENCY AND FEELINGS OF INADEQUACY.

IMPRESSION:
BASED ON CASE HISTORY, MENTAL STATUS EXAMINATION AND
PSYCHOLOGICAL ASSESSMENT, THE FINDINGS ARE INDICATIVE OF
PSYCHOTIC DISORDER COMORBID WITH HALLUCINATORY FEATURES.

EXAMINER SUPERVISOR

SIGNATURE SIGNATURE

DATE DATE
 CASE STUDY 3

IDENTIFICATION DATA
NAME: MR. V.G
AGE: 20YEARS
GENDER: MALE
EDUCATIONAL QUALIFICATIONS: 11TH CLASS
OCCUPATION: WORKED AT MEDICAL STORE(PART
TIME JOB)
MARITAL STATUS: UNMARRIED
SOCIO-ECONOMIC STATUS: LOWER MIDDLE CLASS
ADDRESS GOMTI NAGAR
PLACE OF RESIDENCE: RURAL
NATIONALITY INDIAN
LANGUAGE HINDI
INFORMANTS: PATIENT
RELIABILITY AND ADEQUACY Of : NOT RELIABLE AND INADEQUATE
INFORMATION

PRESENTING COMPLAINTS (FROM PATIENT)

SMACK LETA THA , INJECT OR ORAL DONO LIYA HAI
AJEEB SA LAG RHA
HAATH PAIRO MAI DARD
SAR DARD
ULJHAN LAGTA HAI
GABRAHHAT SI HOTI HAI
GUSSA AANE LAGTA THA

CHIEF COMPLAINTS (WITH DURATION)

CONSUMTION OF OPIOIDS(SMACK) – JUNE 2021
FIDGETING

LOW MOOD

ELVATED MOOD

INSOMNIA

BODY PAIN - 6MONTHS

HEADACHE - OFTEN

IRRITABILITY

ANGER ISSUE(SHORT TEMPER)

SHAKY LEGS

MODE OF ONSET:INSIDIOUS
COURSE:CONTINUOUS
PROGRESS:IMPROVING

PREDISPOSING FACTOR: CONSUMPTION OF CIGARETE, ALCOHOL,

OPIOID(SMACK- ORAL AND INJECT) DUE TO SOCIAL SETTING
PRECIPITATING FACTOR: PEER INFLUENCE
PERPETUATING FACTOR: PEER INFLUENCE AND SELF INVOLVEMENT

HISTORY OF PRESENT ILLNESS:

ACCORDING TO THE INDEX PATIENT, MR V.G IS 20 YEARS OLD, WAS
MAINTAINING WELL UNTILL 2016 AFTER WHICH HE STARTED CONSUMING
CIGARETTE DUE TO THE INFLUENCE OF THE PEER, THEN STARTED CONSUMING
ALCOHOL ON WEEKENDS, LATER IN JUNE 2021 HE STARTED CONSUMING
OPIOIDS(SMACK) ORALLY AND CANNABIS(WEED) IN AUGUST 2021 AFTER WHICH
ON EVERDAY BASIS HE TAKE SMACK AND WEED SIMULTANEOUSLY. FOR
AROUND 4 MONTHS(NOVEMBER, 2022 – FEBRURARY, 2023)HE INJECT THE
SMACK , EVERYDAY HE USE TO INJECT (5ML -10 ML) I.E 2 INJECTIONS PER DAY.
HE STARTED SHOWING SYMPTOMS OF IRRITABLITY, AGGRESSIVE BEHAVIOUR,
HEADACHE, BODY PAIN, SHAKING LEGS, ANXIETY AND BODY FIDGETING WHEN
NOT TAKEN SUBSTANCE OR NOT GETTING.
HE HAD DECREASED SLEEP AND APPETITE. HE HAD BEEN INTO TREATMENT OF
LUNGS HAVING BREATHING PROBLEM, HE WAS BEEN INTO MEDICATION FOR 2-3
MONTHS.HE HAD STRAIN RELATIONS WITH HIS PARENTS AND HAS CORDIAL
HOME ENVIRNOMENT AND FRIENDS RELATIONS. HE WAS AN ABOVE AVERAGE
STUDENT IN SCHOOL BEEN INTERESTED IN SPORTS(KABADDI). HE HAD
MULTIPLE RELATIONSHIPS AND BEEN INTO SEXUAL ACTIVITIES.
TOTAL DURATION OF ILLNESS: 2YEARS
BIOLOGICAL FUNCTIONS:
SLEEP: DECREASED
APPETITE: DECREASED
NEGATIVE HISTORY:

 THERE IS NO HISTORY SUGGESTIVE OF BRAIN TRAUMA/INJURY


THERE IS NO HISTORY SUGGESTIVE OF HEARING OF VOICES NOT HEARED
BY OTHERS OR SEEING OBJECTS OR IMAGES NOT SEEN BY OTHERS

THERE IS NO HISTORY SUGGESTIVE OF IRRATIONAL FEAR

THERE IS NO HISTORY SUGGESTIVE OF SUICIDAL IDEATION

TREATMENT HISTORY:
LUNGS PROBLEM (BREATHING ISSUES) – BEEN ON MEDICATION FOR 2-3 MONTHS

PAST HISTORY:
BODY PAIN
ANGER ISSUES

IRRITIBLITY

FAMILY HISTORY:
FATHER’S NAME – SHRI PRAIJIN GAUTAM(AGE 45+YEARS)

MOTHER’S NAME – MRS PREMA DEVI(AGE 40+YEARS)

ELDER BROTHER’S NAME – SURENDRA GAUTAM(AGE 23+YEARS) - MARRIED

ELDER SISTER’S NAME – MRS POONAM GAUTAM(AGE 21+) – MARRIED

YOUNGER SISTER’S NAME – MS ANJALI GAUTAM(AGE 16YEARS)

YOUNGER BROTHER’S NAME – MR ABHISHEK GAUTAM(AGE 12YEARS)

PRIMARY EARNING MEMBER - FATHER

NO HISTORY OF MENTAL ILLNESS IN THE FAMILY AS REPORTED BY THE

PATIENT

PERSONAL HISTORY (TO BE PRESENTED UNDER FOLLOWING HEADINGS)

 DEVELOPMENTAL HISTORY (THIS HEADING WILL INCLUDE PRENATAL
HISTORY, BIRTH COMPLICATIONS, NATURE OF DELIVERY, DEVELOPMENTAL
MILESTONES ETC)
NO BIRTH COMPLICATION AND NORMAL DELIVERY AS REPORTED BY THE
PATIENT

 PRESENCE OF EARLY CHILDHOOD DISORDERS

COULBN’T BE ELICITED

 HOME ENVIRONMENT

CORDIAL

 SCHOLASTIC HISTORY (WILL ALSO INCLUDE PLAY BEHAVIOR)

ABOVE AVERAGE STUDENT

INTERESTED IN SPORTS LIKE KABADDI

 VOCATIONAL HISTORY
WORKED AS A PAINTER
WORKING IN MEDICAL STORE

WORKED IN WELDINGSHOP IN TAMIL NADU FOR 4 MONTHS

 SEXUAL HISTORY

THE PATIENT WAS SEXUALLY ACTIVE

 LIVING CONDITIONS (WHO ALL IN FAMILY, ROOMS, INCOME, EARNING

MEMBERS ETC)

THE PATIENT HAS FATHER, MOTHER AND 4 SIBLINGS, BELONGS TO A NUCLEAR

FAMILY AND HIS FATHER IS THE EARNING MEMBER IN THE FAMILY

PREMORBID PERSONALITY:
 SELF- STABLE AND HAPPY, LOVING
 RELATION- CLOSE AND HAPPY RELATION WITH FRIENDS BUT STRAIN
WITH PARENTS
 WORK AND LEISURE- CURRENTLY DOING PART TIME JOB AND USE OF
MOBILE
 MOOD- HAPPY
 CHARACTER- KIND AND LOVING
 ATTITUDE- RESPECTFUL
 HABITS- USE OF MOBILE PHONE AND FOLLOWING HIS ROUTINE

 HOBBIES – TRAVELLING,DANCE,BOXING AND PLAYING GAMES

IMPRESSION: THE PATIENT WAS WELL-ADJUSTED AS HE ANWERED ALL THE
QUESTIONS. HE USE TO BE HAPPY, ENJOY MORE AND BEEN INTERESTED BEFOR
THE CONSUMPTION OF SMACK BUT LATER HE DEVELOP ANGER ISSUES AND
BEEN MORE INTO MOBILE PHONES , UNINTERESTED AND ALONE. HE STARTED
SHOWING WITHDRAWAL SYMPTON AS IRRITATION, ANXIETY BODY PAIN WAS
PRESENT.

BEHAVIORAL OBSERVATION/MENTAL STATUS EXAMINATION

 GENERAL APPEARANCE AND BEHAVIOR: THE PATIENT WAS WELL KEPT

AND TIDY, DRESSED APPROPRIATELY, COOPERATIVE AND RAPPORT WAS
ESTABLISHED
 ATTITUDE AND RELATIONSHIP TO EXAMINER: THE PATIENT WAS
RESPECTFUL, PARTIAL EYE CONTACT AND INTERESTED
  MOTOR BEHAVIOR:THE PATIENT HAD FIDGETING BODY MOVEMENT ,
SHIVERING OF LEGS AND WITH DISTRACTIVE BEHAVIOUR.
 SPEECH: THE PATIENT WAS AUDIBLE WITH CLEAR SPEECH AND WITH
NORMAL RANGE OF PITCH

COGNITIVE FUNCTIONS
 ATTENTION AND CONCENTRATION: ATTENTION WAS AROUSED AND
SUSTAINED

 ORIENTATION

TIME - INTACT
PLACE - INTACT
PERSON - INTACT

 MEMORY

IMMEDIATE – INTACT(EXCEPT – 2 FORWARD AND 1 BACKWARD)

RECENT - INTACT
REMOTE - INTACT

 THINKING ABILITY: CONCRETE

 GENERAL FUND OF INFORMATION: AVERAGE

 CALCULATIONS: THE PATIENT WAS ABLE TO SOLVE SIMPLE

MATHEMATICAL CALCULATIONS

INTELLIGENCE: ABOVE AVERAGE LEVEL OF INTELLECTUAL FUNCTIONING

AFFECT:

SUBJECTIVE-
AJEEB SA MEHSOOS HORA
GABRAHHAT SA LAGTA HAI
DARE HUE THE AB THIK HAI
OBJECTIVE-
ANXIOUS

THOUGHT – HELPLESSNESS

PERCEPTUAL DISORDERS: (HALLUCINATIONS AND ILLUSIONS)

NO ABNORMALITY DETECTED

JUDGMENT – TEST, SOCIAL, PERSONAL

THE PATIENT GAVE A SATISFACTORY ANSWERS IN ALL THE THREE DOMAIN

INSIGHT: GRADE IV – AWARENESS OF BEING SICK BUT BLAMING TO INTERNAL

FACTOR

PROVISIONAL DIAGNOSIS:
F19 – MENTAL AND BEHAVIOURAL DISORDERS DUE TO MULTIPLE DRUG USE
AND USE OF OTHER PSYCHOACTIVE SUBSTANCE
F19.26 DEPENDENCE SYNDROME- CURRENTLY ABSTINENT, BUT IN A PROTECTED
ENVIRONMENT

ASSESSMENTS ADMINISTERED
NAME OF THE
SL. NO. TEST RAW SCORE RATIONALE

HAMILTON
ANXIETY MODERATE TO
1 26
RATING SCALE SEVERE
(HAM - A)

ALCOHOL, TOBACCO – 9 MODERATE

2 SMOKING AND ALCOHOL – 20 MODERATE
 CANNABIS – 0 LOW
OPIOIDS – 38 HIGH
SUBSTANCE
INVOLVEMENT

TEST BEHAVIOR:
THE PATIENT WAS COOPERATIVE AND RESPECTFUL YET HE HAD SHIVERING
LEGS, DISTRACTIVE AND FIDGETING WHILE THE CONDUCTION OF THE
ASSESSMENTS.

TEST FINDINGS:THE TEST FINDINGS ARE INDICATIVE OF SUBSTANCE USE

TENDENCIES.
IN HAM-A ,THE SYMPTOMS OF SOMATIC ANXIETY WAS EVIDENT FROM THE
PHYSICAL APPERENCE OF THE PATIENT. THE SCORE OBTAINED WAS 26 WHICH
IMPLIES THAT HE HAS MODERATE TO SEVERE LEVEL OF ANXIETY.
IN ASSIST, THE PATIENT HAS MODERATE LEVEL OF RISK IN THE CONSUMPTION
OF TOBACCO AND ALCOHOL WHICH IMPLIES THAT HE IS AT RISK OF HEALTH
AND OTHER PROBLEMS FROM HIS CURRENT PATTERN OF SUBSTANCE USE.THE
PATIENT HAD LOW LEVEL OF RISK IN CANNABIS WHICH SHOWS THAT HE IS AT
LOW RISK OF HEALTH AND OTHER PROBLEMS FROM HIS CURRENT PATTERN OF
USE. LASTLY, THE PATIENT HAD HIGH LEVEL RISH IN THE CONSUMPTION OF
OPIOIDS WHICH INDICATES THAT HE IS AT HIGH RISK OF EXPERIENCING SEVERE
PROBLEMS(HEALTH, SOCIAL, FINANCIAL, LEGAL, RELATIONSHIP) AS A RESULT
OF HIS CURRENT PATTERN OF USE AND ARE LIKELY TO BE DEPENDENT.

IMPRESSION:
BASED ON CASE HISTORY, MENTAL STATUS EXAMINATION AND
PSYCHOLOGICAL ASSESSMENT, THE FINDINGS ARE INDICATIVE OF
SUBSTANCE USE DISORDER COMORBID WITH MODERATE TO SEVERE
LEVEL OF ANXIETY FEATURES.
EXAMINER SUPERVISOR

SIGNATURE SIGNATURE

DATE DATE

CASE STUDY 4

IDENTIFICATION DATA
NAME: MR. D.K
AGE: 29YEARS
GENDER: MALE
EDUCATIONAL QUALIFICATIONS: 9TH CLASS
OCCUPATION: FARMING
MARITAL STATUS: UNMARRIED
SOCIO-ECONOMIC STATUS: LOWER MIDDLE CLASS
ADDRESS TAMANCHAYPUR, GONDA DISTRICT
PLACE OF RESIDENCE: RURAL
NATIONALITY INDIAN
LANGUAGE HINDI
INFORMANTS: PATIENT
RELIABILITY AND ADEQUACY Of : NOT RELIABLE AND INADEQUATE
INFORMATION

PRESENTING COMPLAINTS (FROM PATIENT)

GANJA LIYA HAI 2013 SE PHIR 2020-21 MAI LAGATAAR PEETE THE KABHI KABHI
4-5 DIN MAI BHI LELETE THE
PICHE PEET MAI DARD HOTA HAI
MUMMY ROTI HAI TO BODY MAI PAIN HOTA HAI
HICHKKI AATI HAI
AWAZ SUNAI DETI HAI BEHEN BULATI HAI
BEHEN OR MUMMY SE SAMNE BAAT KRTE HAI

CHIEF COMPLAINTS (WITH DURATION)

CONSUMTION OF CANNABIS(GANJA) - 2013
IRRELEVANT TALK
RESTLESSNESS
LOW MOOD
BACK PAIN
VISUAL HALLUCINATION OF MOTHER AND SISTER
AUDITORY HALLUCINATION OF MOTHER AND SISTER
DISTURBED APPETITE

FLAT EMOTIONS

MODE OF ONSET:INSIDIOUS
COURSE:CONTINUOUS
PROGRESS:IMPROVING

PREDISPOSING FACTOR: CONSUMPTION OF CANNABIS(GANJA) DUE TO

SOCIAL SETTING
PRECIPITATING FACTOR: PEER INFLUENCE
PERPETUATING FACTOR: PEER INFLUENCE AND SELF INVOLVEMENT

HISTORY OF PRESENT ILLNESS:

ACCORDING TO THE INDEX PATIENT, MR D.K IS 29 YEARS OLD, WAS
MAINTAINING WELL UNTILL 2021 AFTER WHICH HE STARTED HEARING OF
VOICES AND IMAGES OF MOTHER AND SISTER NOT HEARD OR SEEN BY OTHERS,
USUALLY HAD BACK PAIN OR SOMETIME BODILY PAIN. HE HAD BEEN
ADMITTED BEFORE IN 2022 AND THEN IN JANUARY 2023 IN GONDA HOSPITAL
AND THEN ON 16 MAY HE WAS BROUGHT TO THE HOSPITAL.
THE PATIENT WAS TOTALLY UNAWARE OF THE FACT THAT FOR WHAT REASON
HE WAS BROUGHT INTO THE HOSPITAL.HE HAD STABLE SLEEP AND DISTURBED
APPETITE.
HE WAS BEEN INTO CANNABIS(GANJA)CONSUMPTION BEFORE DUE TO PEER
INFLUENCE IN 2013 ON 10-20 DAYS OF GAP OF DURATION AND LATER 4-5 DAYS
OF DURATION IN THE CONSUMPTION OF CANNABIS.
HE HAD CORDIAL RELATION WITH HIS FAMILY AND FRIENDS, HAS CORDIAL
HOME ENVIRONMENT.ACCORDING TO THE PATIENT, HIS FATHER WAS VERY
SHORT TEMPERED AND USUALLY BEEN INTO VIOLENT BEHAVIOUR WITH HIS
MOTHER. HIS FATHER DIED DUE TO BLOOD CANCER.
HE USE TO WORK IN SOME HOTEL AND AT THE SAME TIME DO PART TIME JOB,
LATER AFTER HIS FATHER’S DEATH HE LOOK AFTER HIS FARMING IN
LUCKNOW.CURRENTLY THE FAMILY IS FACING FINANCIAL PROBLEM IN HOUSE.
TOTAL DURATION OF ILLNESS: 2-3 YEARS
BIOLOGICAL FUNCTIONS:
SLEEP: STABLE
APPETITE: DISTURBED
NEGATIVE HISTORY:

 THERE IS NO HISTORY SUGGESTIVE OF BRAIN TRAUMA/INJURY


THERE IS NO HISTORY SUGGESTIVE OF IRRATIONAL FEAR

 THERE IS NO HISTORY SUGGESTIVE OF ELVATED MOOD


THERE IS NO HISTORY SUGGESTIVE OF SUICIDAL IDEATION

TREATMENT HISTORY:
OHN PAADE HOSPITAL ADMITTED FOR CONSUMPTION OF CANNABIS WITH PSYCHOTIC
FEATURES – JANURARY 2023

PAST HISTORY:
VISUAL AND AUDITORY HALLUCINATION

FAMILY HISTORY:
FATHER’S NAME – LATE BIKHARI YADAV(AGE 70YEARS)
MOTHER’S NAME – MRS PYARI YADAV(AGE 65YEARS)

ELDER SISTER’S NAME – MRS RAMRATI(AGE 33YEARS) – MARRIED

ELDER SISTER’S NAME – MS ANITA (AGE 30YEARS) - MARRIED

PRIMARY EARNING MEMBER - PATIENT HIMSELF AFTER THE DEATH OF HIS

FATHER

NO HISTORY OF MENTAL ILLNESS IN THE FAMILY AS REPORTED BY THE

PATIENT

PERSONAL HISTORY (TO BE PRESENTED UNDER FOLLOWING HEADINGS)

 DEVELOPMENTAL HISTORY (THIS HEADING WILL INCLUDE PRENATAL
HISTORY, BIRTH COMPLICATIONS, NATURE OF DELIVERY, DEVELOPMENTAL
MILESTONES ETC)
NO BIRTH COMPLICATION AND NORMAL DELIVERY AS REPORTED BY THE
PATIENT

 PRESENCE OF EARLY CHILDHOOD DISORDERS

COULBN’T BE ELICITED

 HOME ENVIRONMENT

CORDIAL

 SCHOLASTIC HISTORY (WILL ALSO INCLUDE PLAY BEHAVIOR)

AVERAGE STUDENT

INTERESTED IN SPORTS LIKE CRICKET

 VOCATIONAL HISTORY
WORKED IN HOTEL – EARN APPROX. 14-15K/MONTH

DO A PART TIME JOB

WORKING IN FARM – EARN APPROX – 10-15K /MONTH

 SEXUAL HISTORY

NIL CONTRIBUTORY
 LIVING CONDITIONS (WHO ALL IN FAMILY, ROOMS, INCOME, EARNING
MEMBERS ETC)

THE PATIENT HAS MOTHER AND SIBLINGS, BELONGS TO A NUCLEAR FAMILY

AND PATIENT HIMSELF IS THE EARNING MEMBER IN THE FAMILY . EARLIER
FATHER AND MOTHER HAS A STRAIN RELATIONS. THE PATIENT HAD A
GIRLFRIEND NAME RANJANA YADAV.

PREMORBID PERSONALITY:
 SELF- STABLE AND HAPPY
 RELATION- CLOSE AND HAPPY RELATION WITH FRIENDS AND FAMILY
 WORK AND LEISURE- STAY AT HOME
 MOOD- HAPPY
 CHARACTER- KIND
 ATTITUDE- RESPECTFUL
 HABITS- FOLLOWING HIS ROUTINE

 HOBBIES – WORKING, MOVIE AND MUSIC.

IMPRESSION: THE PATIENT WAS WELL-ADJUSTED AS HE ANWERED ALL THE
QUESTIONS. HE USE TO BE HAPPY, ENJOY MORE, ENJOY LISTENING TO MUSIC
AND BEEN INTERESTED TO WATCH MOVIES BEFORE THE CONSUMPTION OF
CANNABIS.

BEHAVIORAL OBSERVATION/MENTAL STATUS EXAMINATION

 GENERAL APPEARANCE AND BEHAVIOR: THE PATIENT WAS WELL KEPT

AND TIDY, DRESSED APPROPRIATELY, COOPERATIVE AND RAPPORT WAS
ESTABLISHED
 ATTITUDE AND RELATIONSHIP TO EXAMINER: THE PATIENT WAS
RESPECTFUL, MAINTAINED EYE CONTACT AND INTERESTED
 MOTOR BEHAVIOR:THE PATIENT HAD HAND MOVEMENT WITH
DISTRACTIVE BEHAVIOUR.
 SPEECH: THE PATIENT WAS AUDIBLE WITH CLEAR SPEECH AND WITH
LOW RANGE OF PITCH
COGNITIVE FUNCTIONS
 ATTENTION AND CONCENTRATION: ATTENTION WAS AROUSED AND
SUSTAINED

 ORIENTATION

TIME - INTACT
PLACE - INTACT
PERSON - INTACT

 MEMORY

IMMEDIATE – IMPAIRED(EXCEPT – 1FORWARD)

RECENT - INTACT
REMOTE - INTACT

 THINKING ABILITY: FUNCTIONAL

 GENERAL FUND OF INFORMATION: AVERAGE

 CALCULATIONS: THE PATIENT WAS UNABLE TO SOLVE SIMPLE

MATHEMATICAL CALCULATIONS

INTELLIGENCE: AVERAGE LEVEL OF INTELLECTUAL FUNCTIONING

AFFECT:

SUBJECTIVE-
SAHI LAG RHA HAI
OBJECTIVE-
ELVATED

THOUGHT – HELPLESSNESS

PERCEPTUAL DISORDERS: (HALLUCINATIONS AND ILLUSIONS)

AUDITORY AND VISUAL HALLUCINATIONS WERE DETECTED

JUDGMENT – TEST, SOCIAL, PERSONAL

THE PATIENT GAVE A SATISFACTORY ANSWERS IN ALL THE THREE DOMAIN

INSIGHT: GRADE I – COMPLETE DENIAL OF ILLNESS

PROVISIONAL DIAGNOSIS:
F12 – MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF
CANNABINOIDS
F12.50 PSYCHOTIC DISORDER – SCHIZOPHRENIA LIKE

ASSESSMENTS ADMINISTERED
NAME OF THE
SL. NO. TEST RAW SCORE RATIONALE

HAMILTON
ANXIETY MILD TO
1 19
RATING SCALE MODERATE
(HAM - A)

BRIEF
PSYCHIATRIC
2 RATING
44 MODERATE
SCALE(BPRS)
 PSYCHOTIC
TENDENCIES
HUMAN FIGURE WITH ANXIETY
3 DRAWING TEST AND
DEPRESSIVE
FEATUES

TEST BEHAVIOR:
THE PATIENT WAS COOPERATIVE AND RESPECTFUL YET HE HAD SHIVERING
HANDS, DISTRACTIVE BEHAVIOUR AND FIDGETING DURING THE CONDUCTION
OF THE ASSESSMENTS.
AT FIRST THE PATIENT DIDN’T WANT TO DO WAS SAYING ‘MAAM KUCH AUR
BNA DE’THEN WHEN HE START MAKING IN BETWEEN HE SAYS ‘MUJHSE NAHI
HORA, AAP BNA DIJE’ LATER HE WAS OFTEN CONFIRMING THAT ‘ THIS HAI
MAAM’ . HE COMPLETE THE FIGURE IN 7-8 MINUTES.

TEST FINDINGS:THE TEST FINDINGS ARE INDICATIVE OF PSYCHOTIC

TENDENCIES.
IN HAM – A : THE SYMPTOMS OF SOMATIC ANXIETY WAS EVIDENT FROM THE
PHYSICAL APPERENCE OF THE PATIENT. THE SCORE OBTAINED WAS 19 WHICH
IMPLIES THAT HE HAS MILD TO MODERATE LEVEL OF ANXIETY.
IN BPRS – THE SCORE OBTAINTED BY THE PATIENT WAS 44 WHICH IMPLIES THAT
HE HAS MODERATE LEVEL OF PSYCHOTIC SYMPTOMS.
IN HFDT – SMALL SIZE IS INDICATIVE OF ANXIETY AND DEPRESSIVE
TENDENCIES WHICH INCLUDE WITHDRAWAL, FEELING OF INFERIORITY AND
SMALLNESS. TOP PLACEMENT IS ASSOCIATED WITH OPTIMISIM WHICH INCLUDE
SEEKING SATISFACTION IN FANTASY, WITH LOW ENERGY LEVEL AND
DIFFICULTY ATTAINING GOALS. LEFT PLACEMENT IS RELATED TO
UNCERTAINITY, APPREHENSIVENESS AND GENERAL FOCUS CONCERN WITH THE
PAST EVENTS. GROSS DISPROPORTION IS INDICATIVE OF SEVERE DISTURBANCE
RELATED TO VERY POOR REALITY CONTACT OR AN ORGANIC CONDITIONS SUCH
AS ALCOHOLISM AND PSYCHOSIS. STICK FIGURE AND PRIMITIVE APPEARANCE
HAVE INCLUDED AGITATED DEPRESSION, RIGIDITY AND PSYCHOPATHY AND
FOUND TO BE EXPERIENCING SEVERE COGNITIVE IMPAIRMENT. SPIKED FINGERS
HAVE BEEN ASSOCIATED WITH AGGRESSIVENESS, BUT WITHOUT THE
ASSUMPTION OF ORAL INVOLVEMENT. GEOMETRIC SHAPES FOR BODY PARTS
INDICATES ORGANIC OR SEVERE PSYCHOTIC CONDITIONS. HEAVY LINES HAVE
BEEN ATTRIBUTED TO MOOD VOLATILITY WITH TENSE EMOTIONAL STATE..
REINFORCED LINES SUGGEST DEFENSE MECHANISM AS PROTECTION FROM
DEPERSONALISATION, CONFLICT AND FEELINGS OF EXTREME VULNERABILITY.
GENDERLESS DRAWINGS ARE TYPICALLY IN THE DEVELOPMENTALY DELAYED,
THEY ARE SUGGESTIVE OF A CONDITION OF COGNITIVE AND EMOTIONAL
REGRESSION. CHILDLIKE FIGURES ARE ASSOCIATED WITH DEPENDENCY.
DEVELOPMENTALLY INDISTINGUISHABLE FIGURES SUGGEST WITHDRAWN AND
REGRESSED EMOTIONAL STATES. WAIST NOT INDICATED IMPLIES PREMITIVE
AND SEVERELY DYSFUNCTIONAL SUBJECTS. PUPILS OMITTED AND CHICKEN
FEET HAVE BEEN ASSOCITED WITH IMMATURITY, RELACTANCE TO ACCEPT
VISUAL STIMULI AND GUILT FOR VOYEURISTIC TENDENCIES. HEAD OMITTED
ARE INDICATIVE OF SEVERLY IMPAIR AND PARANOID SCHIZOPHRENIA WERE
REPRESENTED HAIR AND NOSE OMITTED HAS BEEN ASSOCIATED WITH
FEELINGS OF SEXUAL INADEQUACY. NECK OMITTED IS CONSIDERED TO
REPRESENT A BARRIER TO THE FREE FLOW OF IMPULSES BETWEEN THE HEAD
AND BODY. TRUNK OMITTED INCLUDES POOR BODY IMAGE, REJECTION OF
PHYSICAL IMPULSES AND DENIAL OF BODY DRIVES AND LASTLY STEREOTYPED
ARE INTERPRETATED AS FANCY PROJECTIONS OF THE SELF, WITH THE SELF
PROJECTION BEING EITHER SELF AGGRANDIZING OR SELF DEPRECIATING.
OVER ALL FINDINGS ARE SUGGESTIVE OF ANXITY AND DREPESSION TENDENCY,
IMPAIRMENT IN REALITY TESTING, POOR SELF CONCEPT, POSSIBLE
DEPENDENCY AND FEELINGS OF INADEQUACY.

IMPRESSION:
BASED ON CASE HISTORY, MENTAL STATUS EXAMINATION AND
PSYCHOLOGICAL ASSESSMENT, THE FINDINGS ARE INDICATIVE OF
PSYCHOTIC DISORDER COMORBID WITH SCHIZOPHRENIC FEATURES.

EXAMINER SUPERVISOR

SIGNATURE SIGNATURE

DATE DATE
 CASE STUDY 5

IDENTIFICATION DATA
NAME: MR. A.K
AGE: 33YEARS
GENDER: MALE
EDUCATIONAL QUALIFICATIONS: POST GRADUATED IN SOCIOLOGY
OCCUPATION: CENTRAL GOVERNMENT EMPOLYEE
- CHARBAGH
MARITAL STATUS: MARRIED
SOCIO-ECONOMIC STATUS: MIDDLE CLASS
ADDRESS LUCKNOW AND BARABANKI
PLACE OF RESIDENCE: URBAN
NATIONALITY INDIAN
LANGUAGE HINDI
INFORMANTS: PATIENT
RELIABILITY AND ADEQUACY Of : NOT RELIABLE AND ADEQUATE
INFORMATION

PRESENTING COMPLAINTS (FROM PATIENT)

PEETE THE OR AB AISA HOTA HAI KI PEENE KE BAAD 2 DIN TAK LAPATA HO
JAATE HAI
YAAD NAHI RHETA KAL RAAT KYA HUA THA
GABRAHHAT HOTI THI PEENE SE PHELE
CHIDHCHIDAPAN JAB BHEEDH MAI HOTE HAI
BHAGNE KA MAN KRTA HAI
EMOTIONS KHATUM HOGYE HAI
PHELE SE AKELE RHENE KA MAN KRTA HAI
ANGER ISSUES HAI
VOCAL SOUND BAND HO JAATE HAI PEENE BAAD

CHIEF COMPLAINTS (WITH DURATION)

CONSUMPTION OLF ALCOHOL – SINCE 2005
AGGRESSIVE BEHAVIOUR – 2018

IRRITABLITY

RECENT MEMORY LOSS

RESTLESSNESS – 4-5 TIMES

FLAT EMOTIONS

UNABLE SPEAK AFTER CONSUMING ALCOHOL – WHEN HEAVY DRINK

FEELING OF LONELINESS

SHAKING LEGS

SHIVERING HANDS

MODE OF ONSET:INSIDIOUS
COURSE:CONTINUOUS
PROGRESS:STATIC

PREDISPOSING FACTOR: FAMILY HISTORY OF CONSUMPTION OF ALCOHOL

AND OWN WILL TO TAKE
PRECIPITATING FACTOR: PEER INFLUENCE AND FAMILY CONFLICTS
PERPETUATING FACTOR: SELF ADDICTED TO THE SUBSTANCE

HISTORY OF PRESENT ILLNESS:

ACCORDING TO THE INDEX PATIENT, MR A.K IS 33 YEARS OLD, WAS
MAINTAINING WELL UNTILL 2018 AFTER WHICH HE STARTED CONSUMING
CIGARETTE, BEER AND ALCOHOL ON REGULAR BASIS DUE TO PEER INFLUENCE,
FAMILY CONFLICTS AND FAMILY HISTORY OF DRINKING. LATER HE BECOME A
BINGE DRINKER AND AFTER HE WAS SHOWING THE SYMPTOMS OF
IRRITABILITY, AGGRESSIVE BEHAVIOUR, FEELING OF LONELINESS, RECENT
MEMORY LOSS, FLAT EMOTION AND UNABLE COME BACK HOME FOR 2 DAYS
DIDN’T REMEMBER WHERE HE WAS, AFTER TWO DAYS WHEN HE WAKE UP HE
WAS MOSTLY FOUND IN CHARBAGH, TELIBAGH AND BARABANKI. HE WAS
UNABLE TO SPEAK WHEN CONSUME ALCOHOL IN HIGH QUANTITY.HE FIRST
TRIED IN 2005 ON HIS OWN WILL THEN IN COLLEGE TIME WITH HIS FRIENDS IN
2008. HE USE TO SMOKE EVERYTIME WHEN DRINK.
HE HAS STRAIN RELATION WITH HIS WIFE BECAUSE OF HIS ALCOHOL
CONSUMPTION AND BEING SUSPICIOUS THAT HE HAS AN EXTRA MARITAL
AFFAIR OUTSIDE THE HOUSE. THE PATIENT HAD A LOVE MARRIAGE AND LATER
WIFE HAD BEEN INTO DEPRESSION WAS ON MEDICATION IN KGMC.
HE HAS DISTURBED SLEEP AND LACK OF APPETITE AFTER THE CONSUMPTION
OF ALCOHOL AND ALSO HAD MULTIPLE JOB IN HIS PAST TIME.
TOTAL DURATION OF ILLNESS: 6YEARS
BIOLOGICAL FUNCTIONS:
SLEEP: DISTURBED
APPETITE: STABLE BUT DECREASED AFTER CONSUMPTION OF ALCOHOL
NEGATIVE HISTORY:

 THERE IS NO HISTORY SUGGESTIVE OF BRAIN TRAUMA/INJURY


THERE IS NO HISTORY SUGGESTIVE OF HEARING OF VOICES NOT HEARED
BY OTHERS OR SEEING OBJECTS OR IMAGES NOT SEEN BY OTHERS

THERE IS NO HISTORY SUGGESTIVE OF IRRATIONAL FEAR
 THERE IS NO HISTORY SUGGESTIVE OF LOW MOOD AND ELEVATED MOOD

THERE IS NO HISTORY OF SUICIDAL IDEATION

TREATMENT HISTORY:
COULD NOT BE ELICITED

PAST HISTORY:
ANGER ISSUES SINCE CHILDHOOD
FAMILY HISTORY:
THE PATIENT HAS A JOINT FAMILY BUT LIVES LIKE A NUCLEAR ONE AND
HAS STRAIN RELATION WITH HIS WIFE
IN FAMILY EVERYONE DRINKS
FATHER’S NAME – LATE SHRI CHAUHAN(DIED DUE KIDNEY FAILURE)

MOTHER’S NAME – LATE RAMPATI DEVI(DIED DUE TO HEART ATTACK)

ELDER BROTHER’S NAME – MR RAM NARAYAN KUMAR(AGE 55YEARS) -

MARRIED

ELDER BROTHER’S NAME – MR NANDLAL KUMAR(AGE 52YEARS) – MARRIED

ELDER BROTHER’S NAME – MR ARVIND KUMAR(AGE 36YEARS) – MARRIED

ELDER BROTHER’S NAME – MR BHUPENDRA KUMAR(AGE 35YEARS) - MARRIED

YOUNGER BROTHER’S NAME – MR ANKIT KUMAR (AGE 31YEARS)

PRIMARY EARNING MEMBER - PATIENT HIMSELF

NO HISTORY OF MENTAL ILLNESS IN THE FAMILY AS REPORTED BY THE

PATIENT

PERSONAL HISTORY (TO BE PRESENTED UNDER FOLLOWING HEADINGS)

 DEVELOPMENTAL HISTORY (THIS HEADING WILL INCLUDE PRENATAL
HISTORY, BIRTH COMPLICATIONS, NATURE OF DELIVERY, DEVELOPMENTAL
MILESTONES ETC)
NO BIRTH COMPLICATION AND NORMAL DELIVERY AS REPORTED BY THE
PATIENT

 PRESENCE OF EARLY CHILDHOOD DISORDERS

COULBN’T BE ELICITED
  HOME ENVIRONMENT

CORDIAL BUT STRAIN AFTER THE CONSUMPTION OF ALCOHOL

 SCHOLASTIC HISTORY (WILL ALSO INCLUDE PLAY BEHAVIOR)

AVERAGE STUDENT

INTERESTED IN SPORTS LIKE CRICKET

 VOCATIONAL HISTORY
WORKED IN BANK OF BARODA

WORKED IN RAILWAY- RMS

COSMETIC SHOWROOM OF ALL BRANDS

MAKE YOUTUBE VIDEOS, FACEBOOK PAGE, INSTAGRAM

 SEXUAL HISTORY

THE PATIENT WAS SEXUALLY ACTIVE.

 MARITAL HISTORY

IT WAS A LOVE MARRIAGE , DATED FOR THREE YEARS AND GOT MARRIED IN
2014 AND HAVE A DAUGHTER IN 2017. FOR MARRIAGE THE PAIENT TOOK A LOAN
ALSO.WIFE HAS BEEN INTO SEESION FOR DEPRESSION IN KGMC AND HAS ANGER
ISSUES TOO

 LIVING CONDITIONS (WHO ALL IN FAMILY, ROOMS, INCOME, EARNING

MEMBERS ETC)

THE PATIENT HAS A JOINT FAMILY WITH 5 SIBLINGS AND EVERYONE HAS
THERE OWN NUCLEAR FAMILY AND ACCORDINGLY EARNING MEMBERS ARE
THEMSELVES DISTRIBUTED.

PREMORBID PERSONALITY:
 SELF- STABLE BUT UNHAPPY WHEN ALCOHOL NOT CONSUMED
 RELATION- STABLE RELATION WITH FAMILY AND FRIENDS
  WORK AND LEISURE- USE TO DRINK AND WORK TO MAKE MONEY
 MOOD- HAPPY
 CHARACTER- KIND
 ATTITUDE- RESPECTFUL
 HABITS- FOLLOW HIS ROUTINE
 HOBBIES – COULD NOT BE ELICITED
IMPRESSION: THE PATIENT WAS WELL-ADJUSTED AS HE ANWERED ALL THE
QUESTIONS. HE USE TO BT HAPPY HAD CORDIAL RELATION WITH EVERYONE IN
FAMILY AND SOCIAL SITUATION DUE TO HIS BINGE DRINKING HE HAD STARIN
RELATION WITH HIS WIFE AND WANT TO MAKE MONEY SO THAT HE CAN PAY
HIS DEBT, BUY PROPERTY AND TAKE CARE OF CHILD FOR HER BETTER FUTURE.

BEHAVIORAL OBSERVATION/MENTAL STATUS EXAMINATION

 GENERAL APPEARANCE AND BEHAVIOR: THE PATIENT WAS WELL KEPT

AND TIDY, DRESSED APPROPRIATELY, COOPERATIVE AND RAPPORT WAS
ESTABLISHED
 ATTITUDE AND RELATIONSHIP TO EXAMINER: THE PATIENT WAS
RESPECTFUL, MAINTAINED EYE CONTACT AND INTERESTED
 MOTOR BEHAVIOR:THE PATIENT HAD SHIVERING OF HANDS.
 SPEECH: THE PATIENT WAS AUDIBLE WITH CLEAR SPEECH AND WITH
LOW TO NORMAL RANGE OF PITCH

COGNITIVE FUNCTIONS
 ATTENTION AND CONCENTRATION: ATTENTION WAS AROUSED AND
SUSTAINED

 ORIENTATION

TIME - INTACT
PLACE - INTACT
PERSON - INTACT

 MEMORY

IMMEDIATE – INTACT(EXCEPT – 1 FORWARD)

RECENT - IMPAIRED
REMOTE - INTACT

 THINKING ABILITY: CONCRETE

  GENERAL FUND OF INFORMATION: AVERAGE

 CALCULATIONS: THE PATIENT WAS ABLE TO SOLVE COMPLEX

MATHEMATICAL CALCULATIONS

INTELLIGENCE: ABOVE AVERAGE LEVEL OF INTELLECTUAL FUNCTIONING

AFFECT:

SUBJECTIVE-
THIK LAG RHA HAI
GHAR JA KAR ARAM KRENGE
OBJECTIVE-

EUPHORIC

THOUGHT – HOPELESSNESS

PERCEPTUAL DISORDERS: (HALLUCINATIONS AND ILLUSIONS)

NO ABNORMALITY DETECTED

JUDGMENT – TEST, SOCIAL, PERSONAL

THE PATIENT GAVE A UNSATISFACTORY ANSWERS IN ALL THE THREE DOMAIN

INSIGHT: GRADE IV – AWARENESS OF BEING SICK BUT BLAMING TO INTERNAL

FACTOR

PROVISIONAL DIAGNOSIS:
F10 – MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF ALCOHOL
F10.26 DEPENDENCE SYNDROME – CURRENTLY ABSTINENT,BUT IN A PROTECTED
ENVIRONMENT
F17 – MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF TOBACCO
F17.26 DEPENDENCE SYNDROME- CURRENTLY ABSTINENT, BUT IN A PROTECTED
ENVIRONMENT
ASSESSMENTS ADMINISTERED
NAME OF THE
SL. NO. TEST RAW SCORE RATIONALE

ALCOHOL, TOBACCO – 20 MODERATE

1 SMOKING AND ALCOHOL – 25 MODERATE
SUBSTANCE
INVOLVEMENT
SCREENING
TEST(ASSIST)

TEST BEHAVIOR:
THE PATIENT WAS COOPERATIVE AND RESPECTFUL YET HE HAD SHIVERING
HANDS AND WAS TAKING TIME IN ANSWERING THE QUESTIONS IN THE
CONDUCTION OF THE ASSESSMENTS.
TEST FINDINGS:THE TEST FINDINGS ARE INDICATIVE OF SUBSTANCE USE
TENDENCIES.
IN ASSIST, THE PATIENT HAS MODERATE LEVEL OF RISK IN THE CONSUMPTION
OF TOBACCO AND ALCOHOL WHICH IMPLIES THAT HE IS AT RISK OF HEALTH
AND OTHER PROBLEMS FROM HIS CURRENT PATTERN OF SUBSTANCE USE.
IMPRESSION:
BASED ON CASE HISTORY, MENTAL STATUS EXAMINATION AND
PSYCHOLOGICAL ASSESSMENT, THE FINDINGS ARE INDICATIVE OF SUBSTANCE
USE DISORDER COMORBID WITH MILD LEVEL OF DEPRESSIVE FEATURES.

EXAMINER SUPERVISOR
SIGNATURE SIGNATURE

DATE DATE

CONCLUSION
THE SUMMER INTERNSHIP AT IMHRC WAS TRULY AN EYE OPENING AND A
GREAT INSIGHT TOWARDS THE PROFESSION WHICH I CHOSE. HAVING A GOOD
KNOWLEDGE ON THEORY AS WELL AS PRACTICE WILL MAKE YOU THE ONE
WHO CAN BE THE TRUE MEDIATOR TO THE PATIENT FOR THEIR HEALING.

I HAVE ALSO LEARNED THE IMPORTANCE OF RAPPORT BUILDING AND

DETAILED CASE HISTORY. I ALSO OBSERVED DIFFERENT TYPES OF DISORDERS
AND LEARNED DIFFERENT TYPES OF ASSESSMENTS. AN ACCURATE EMPATHY,
QUESTIONING SKILLS, ACTIVE LISTENING ,DEEP THEORETICAL AND PRACTICAL
KNOWLEDGE CAN HELP AN ASPIRING STUDENT IN THE PSYCHOLOGY FIELD TO
FACILITATE PSYCHO EDUCATION AND MENTAL CARE.
 KEY LEARNINGS

 LEARNT AND OBSERVED THE ROLE OF A CLINICAL PSYCHOLOGIST.

 LEARNED HOW TO ESTABLISH RAPPORT WITH THE PATIENTS AND THEIR

CAREGIVERS.

 LEARNED HOW TO DEAL WITH DIFFERENT KIND OF PATIENTS AND HANDLE

THEM PROPERLY.

 LEARNED HOW TO TAKE CASE HISTORIES, AND MENTAL STATUS

EXAMINATION (MSE) AND PROCEED WITH THE BASIC ASSESSMENT TOOLS

WITH THE PATIENT.

 LEARNED ABOUT DIFFERENT TYPES OF MENTAL DISORDERS, THEIR

SYMPTOMS, AND TREATMENTS.

 LEARNED HOW TO PROVIDE PSYCHOEDUCATION TO THE PATIENTS AS WELL

AS THE FAMILY MEMBERS.

 REFERENCES

 A short text book of psychiatry –Neeraj Ahuja -7th edition

 ICD -10 –classification of mental and behavioural disorders

 https://imhrc.org