1

Task – 3

Submitted by -:

Fardeen Rafique
 2

Purpose of the presentation: Management

Sociodemographic details: Mr R , 33 year old Sikh, unmarried male, belonging to

urban middle class joint family, studied upto B.Tech, currently unemployed

Informants: Self and Mother

Chief complaints

According to the Mother

 ““ajeeb harkatein karta hai”

 “kuch khaata nahi theek se, bas room mai baitha rehta hai”

According to the Client

 “nasha hota tha , toh maine anti-nuclear banaya”

 “mere kamre mai paranormal activity hoti hai”

Onset – Acute Course – Insidious Progress – Deteriorating

History of presenting illness

The patient was apparently keeping well till 2006, when he was 20 yrs old and studying

in the final semester of his diploma. This is when family noticed that he had started

washing his hands excessively and sometimes also re-washed the clean utensils, fearing

„kitnau‟ (germs)

In 2007, at age 21 yrs, he got into a college in Punjab for his B.Tech degree. He joined

the course and shifted to the hostel inside the campus. After two months of starting the

course, the family got a call from the warden stating that Mr R had not come out of his

room since past 2 weeks. This worried the mother and she went to Punjab with the
 3

intention of staying with him. On her arrival, she noticed that the whole room was a mess

with things thrown around the floor and Mr R seemed unkempt and as if he hadn‟t taken

a bath in a long time. On being asked by his mother to attend classes, he refused to

comply. After being persuaded by the mother, he started going to the college. But the

mother used to accompany him till the college gate. 

In 2010, at 25 yrs , in his third year of B.Tech his family took him to Hoshiarpur to a

psychiatrist and he was started on medications. He continued going to college and

cleared all his papers except one.

Meanwhile, he came back to Delhi for the 6 month compulsory training in 2011.

During this time, his aggressive behaviour had increased. His mother noticed that he

used to sit in the corner of the room and appeared to be talking and muttering to self.

He would also make some gestures in the air and seemed as if he was having a

„conversation‟ He was then taken to IHBAS for psychiatric consultation and started on

anti- psychotics and started getting better.

In 2012, at 27 yrs of age, he received his B.Tech degree after clearing that last paper. As

reported, he almost reached his premorbid functioning with these medicines. He started

taking care of himself, started saving money and spent time with his family. He landed a

job at a private firm in Delhi as an electronics engineer. He continued at that job for 1

year and switched to another the next year due to better prospects.

Since his symptoms were settling down, his medicines were being gradually tapered off.

Towards the end of 2015, when he was 30 yrs old, he started getting increasingly

suspicious towards his sister who he thought was giving her „nasha‟ because of which

he was feeling drowsy.

 4

In July 2017, his hand washing had stopped but he started bathing excessively. He used

to bath with hot boiling water 2-3 times a day. His mother noticed this and shouted on

him. This made him furious and he shouted and pushed her and she hit her head on the

steel door which hurt her badly.

Around the same time, he started collecting spiritual texts of his religion from various

gurudwaras. He also started collecting random things from the road, like broken

wires, glass pieces,broken pipes. He also started being suspicious towards his mother,

he used to tell her “you are not my mother..you are a clone” He also complained of

seeing spirits of Gods and his college mates.

On being asked, the patient reported that there were some paranormal activities in his

room, where 987 spirits visited him and asked him to add life back into them. He also

believed that he had „nasha‟ in his body which would be removed only when he eats

„anti-nuclear‟ substance which he made out of pencil. He also reported of being

watched and heard by some external agency , who had installed a machine in his house

to spy on his family.

Diagnostic formulation

A 33 year old Sikh, unmarried, unemployed male living in a joint family in Delhi,

educated upto B.Tech, presented with the complaints of seeing spirits in his room,

hearing them talk and delusions of persecution, decreased self-care, reduced appetite and

sleep since 2 years. He has a family history of father having psychosis (?). MSE revealed

inappropriate dressing, pressured speech, and presence of auditory and visual

hallucinations with delusions of misidentification and persecution; with impaired social

and personal judgement and level 1 insight.

 5

Form the following:

1. Provisional Diagnosis

2. Differential Diagnosis

3. MSE

4. Elicit additional information to fill in the gap

1. PROVISIONAL DIAGNOSIS-:

The provisional diagnosis based on ICD is F20.01: Paranoid schizophrenia, episodic with

progressive deficit.

Points in favour of the diagnosis-:

 First, the criteria for schizophrenia are met as there was a presence of difficulty in

carrying out activities of daily life (for weeks) before the onset of the psychotic episodes,

after which certain hallucinations and delusions began to manifest. Specifically, the onset

of the client, Mr. R’s diagnosed paranoid schizophrenia was found to be acute, episodic/

insidious, with evidence of progressive decline in functioning by the third decade of his

life.

 There is presence of auditory hallucinations, as reported by the informant, the client’s

mother. He was found to be sitting in a corner and talking/ conversing like there was

someone with him. There were also reports of visual hallucinations evident from his

narration of paranormal activity going on in his room and seeing spirits. Moreover, the
 6

client’s mother (as the informant) also reported having observed the client making

gestures in the air, which could also indicate the presence of visual hallucinations.

 There is presence of delusions of persecution which may be considered to be dominating

the clinical picture. The client had a firm belief that his sister was trying to harm him and

keep him in “nasha”, which led him to do something about, thereby, making attempts to

make “antinuclear medicine” which would bring his intoxication down. Moreover, he

believed that there was paranormal activity going on in his room and that he was visited

by over 987 spirits who wanted him to add life back to them. Hence, he tried to protect

himself through the religious texts and scriptures that he frequently started to buy. These

delusions are thematically well-connected. Furthermore, he firmly believed that his

mother was a clone, and not really his mother.

 Impaired volition and social withdrawal with aloofness are evident but do not dominate

the clinical picture. This was evident in how he lagged behind in examinations with

respect to one paper, but was able to pass the others, and finally pursue an advanced

course later and graduated from the same. There was little evidence of cognitive decline

as well.

 Minor incongruity is seen in terms of mood disturbances as reported in attacking or

becoming violent towards the mother.

 Finally, with episodes, the deficits became prominent and the symptoms began to

deteriorate.

2. DIFFERENTIAL DIAGNOSIS –

i. Substance-induced Psychoses-: The client was found to have no history of

chronic or persistent alcohol and substance use. Hence, the client’s diagnosis
 7

of paranoid schizophrenia must be differentially diagnosed from substance-

induced psychoses.

ii. Psychosis due to Organic Causes-: Psychoses due to organic causes must

also be ruled out in diagnosing the client’s condition, as there is no evidence

or history of any early onset dementia or delirium.

iii. Catatonic Schizophrenia-: The clinical picture presented little evidence of

stupor of any kind or of any rigid postures for prolonged periods of time.

iv. Hebephrenic or Disorganized Schizophrenia-: Although impaired volition

and mood incongruity were present, they were less prominent and did not

dominate the clinical picture. This is evident in how the client’s educational

and personal histories show that he was able to clear his almost all of his

courses and exams both before and after he was prescribed anti-psychotics,

and achieve his premorbid functioning once he was put on medications.

v. Undifferentiated and Residual Schizophrenia-: The client’s diagnosis does

not fall into either of the two categories of undifferentiated and residual

schizophrenia.

vi. Delusional disorders and acute and transient psychotic disorders must

also be ruled out.

vii. Depression-: Although some of the symptoms such as being socially

withdrawn and inability to concentrate and maintain appropriate social and

occupational functioning were evident, there was little evidence in the

symptoms of the client for meeting the full diagnostic criteria for depression.
 8

3. MENTAL STATUS EXAMINATION (MSE)-:

I) General Appearance and Behavior:

 Attitude toward the examiner- Unduly suspicious and awkward/ aloof

 Grooming, Hygiene and Dressing – The client was looking unkempt and was

found to be inappropriately dressed.

 Looking Age – Appropriate - The patient looked older than his stated

chronological age.

 Eye to Eye contact- Fleeting eye contact, looking away and around most of the

time.

 Rapport – The rapport building process was characterized by great difficulty as

the client was unduly suspicious and socially awkward.

 Gait and Posture – Unable to maintain a straight posture, and gait was slow and

less coordinated. The client was restless.

 Psychomotor Activity – Displayed odd movements, inability to maintain balance

for a long time, and poor physical coordination.

II) Speech

 Flow- Increased reaction time, and long pauses before answers (thought blocking)

 Rate – Increased, pressured.

 Amount – Decreased, short and fragmented sentences, jumping from one idea to

another.

 Volume – Decreased, mumbling when speaking, slurred speech with whispers and

rigid rhythm.
 9

 Coherence- Incoherent speech, loosening of associations.

 Relevance- Irrelevant, and not goal-directed.

 Prosody of Speech- Absent, diminished

III) Mood and Affect

 Subjective – “Mujhe pata lag gaya hain, meri behen mujhe nasha deti hai aur

mere kamre mein paranormal activity hota hai, isliye maine pencil le antinuclear

banaya aur bhagwan ke kitabe kharide”.

 Objective – Diminished facial grimaces and gestures.

 Affect- Blunted.

IV) Thought:

 Thought Stream- Flight of ideas, circumstantial and tangential

 Possession of Thought- Thought blocking, passivity

 Form of Thought – Formal thought disorders were observed; derailment, word

salad, perseveration, disorganized.

 Thought Content- Presence of delusions, grandeur and control, and additional odd

beliefs-

i. “nasha hota tha, meri behen deti thi , toh maine anti-nuclear banaya” ,

ii. “woh meri maa nahi hain, clone hai, mujhe pata hain”

iii. “koi mujhe aur mere ghar ko dekh raha hain. Kisine machine install

kiya hum pe nazar rakhne ke liye”.

iv. “mere kamre mai paranormal activity hoti hai”

 10

v. “mere paas 987 spirits aaye, unhone mujhe unko duniya mein wapas

aane ke liye help pucha; sirf main hi yeh kar sakta hoon; unhone

mujhe choose kiya”

V) Perception:

The client demonstrated perceptual disturbances in the form of hallucinations. Hallucinations

that were evident were observed to be of the auditory and visual types. The client was observed

to be muttering to himself as if there was someone next to him. He was found to be staring

around as if there was someone present.

i. “Koi mujhe dekh raha hain:

ii. “Who mujhe sun bhi raha hain:

iii. “Maine dekha hain spirits ko mere kamre mein; who mere saath hi rehte hain”

VI) Cognition:

 Level of Consciousness- Drowsy

 Orientation-

vi. What time is it?

vii. Where are you?

viii. Is it day or night?

The client knows where he is, and what time it is.

IMPRESSION: Intact. The client is oriented to space, and time.

 Attention and Concentration – Poor, impaired.

 11

 Memory – Recent and remote memory are impaired

IMPRESSION: Impaired

 General Fund of Knowledge- Impaired

 Abstract Thinking-

Proverbs- i. ‘All that glitters is not gold’, ii. ‘The early bird catches the worm’

Response- The client had no response and demonstrated difficulty in

comprehension.

IMPRESSION- Impaired, unable to understand common proverbs and their

idiosyncratic interpretation.

VII) Judgement:

 Test Judgement - Could not be performed

 Social Judgement – Impaired

 Personal Judgement - Impaired

IMPRESSION: Impaired personal and social judgement

VIII) Insight:

LEVEL 1- The client, Mr. R, was found to be at the first level of insight. That is, he is in

complete denial of his illness, and the problems that may have been persisting as a result of his

illness.

4. FURTHER INFORMATION-:
 12

i. Do you consume alcohol or take any substance besides the medications prescribed to

you?

ii. How well have you been sleeping/ do you have difficulty in sleeping?

iii. Are you still engaging yourself in the things you love doing?

iv. Do you ever have thoughts of harming yourself or suicide?

v. Have you ever seen anyone in your family having similar experiences as you?