Internship Case File by Aabid

CASE STUDY- 1 (Severe depressive episode with psychotic symptoms)
PERSONAL INFORMATION:
Name: FAHEEM AHMAD
Age: 28
Marital status: Married
Gender: Male
Occupation: Software engineer
Education: B tech
Religion: Islam
Mother tongue: Kashmiri
Location of residence Sheerii Baramulla
Socioeconomic status: Middle class
Informant: wife
Reliability: Reliable and consistent
CHIEF COMPLAINTS
According to client
The client reported that when he is alone he feels that someone is talking to him
and scolding him for everything he does. He feels that he has done something
very bad and people want to harm him for that.
According to informant
Wife reported that he is not sleeping and eating well. He sits alone in room most
of time and talks with himself. The symptoms started 2 months ago when client’s
father died in an accident. After the accident he didn’t talk with anyone for long
time and slowly started behaving differently. She mentioned that client has fear
that people want to harm him. He is also suspicious of his wife that she is also
conspiring with others to harm him. He also feels that other people are talking
about him
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HISTORY OF PRESENT ILLNESS
Patient was very restless and agitated. He was not in position to answer anything. He kept
repeating that I want to be normal. Patient was accompanied by his wife. According to wife
he became quiet and distant after his father’s death. He couldn’t sleep well so he took sleeping
pills which helped him in getting sleep. Recently before 1 week he stopped going to office and
remain in his room for most of the time. From last 2 days he is not sleeping and talking to
himself. He suspects that others including his wife trying to harm him because he has done
something bad. His wife also mentioned that he has been aggressive towards other and suspect
that people are talking about him.
Mode of onset: insidious
Duration of illness: 2 months
PAST PSYCHIATRY AND MEDICAL HISTORY
Client does not have any prior psychiatric or medical history
TREATMENT HISTORY
The client took sleeping pills for few days.
BIOLOGICAL FUNCTIONING
Sleep: not sleeping from 2 days
Appetite: low
Sexual interest and activity: low
Energy: low
NEGATIVE HISTORY
No history of head injury, epilepsy, seizures.
FAMILY HISTORY
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There is no consanguinity between parents of the client. Patient lives with his
mother and wife. He had arranged marriage 2.5 years ago. He does not have any
child. He is a software engineer whereas his wife teaches in a school.
PERSONAL HISTORY
Birth order: only child
Birth and development history: normal delivery and milestones were achieved on
time, no childhood disorder present.
Behavior :
The client has been very introverted since childhood. He didn’t have any friends
growing up. He talked very less and focused on his studies. He does not share
much with anyone and talk very less with his mother and wife. He prefers to go
on a solo trip.
Academic History:
The client was very good in academic. He felt anxious when he had to talk or
give presentation in front of people. He once fainted in school because he was
asked to give speech. He likes to go on solo trip.
Occupational History:
Client has been working as a software engineer in MNC from 6 years.
Sexual History:
Data not available.
PRE MORBID PERSONALITY:

The client was introverted , anxious person.
ALCOHOL AND SUBSTANCE HISTORY:

Occasionally consume alcohol
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MENTAL STATUS EXAMINATION
GENERAL APPEARANCE & BEHAVIOR:

General appearance was untidy. He hadn’t combed for two days. Today he didn’t
brush and bath. He was staring at one place and constantly blinking. Client was
lean and looked unhealthy. no eye contact maintained. Rapport could not be
established with the client and there was rude attitude towards the examiner.
Client was not cooperative.
MOVEMENT AND BEHAVIOR:
Slow psychomotor movement was observed from the client. He was staring at
one place and movement was slow. But he was blinking constantly.
SPEECH:
Thought block was absent. monotonous pitch was observed. Speed was increase
and reaction time was slow.
MOOD / AFFECT:
● Subjectively: : “ I am worried about my life ”
● Objectively: cautious
●
THOUGHT:
Form of thought disorder: absent

Delusion: present
Client says, “people are trying to harm me”.
PERCEPTION
Hallucination is absent.
COGNITIVE FUNCTIONS:
● oriented to time, place and person.

● Attention & Concentration around but not sustained
● Memory:
● Immediate memory:
● intact Recent memory:
● intact Remote memory:
● intact
● Abstract thinking impaired.
● Intelligence is impaired
● General fund of knowledge: adequate.
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JUDGMENT:
Personal : Impaired Social

: Impaired
INSIGHT:
Level 2- slight awareness of being sick and needing help, but denying it at the same time.
DIAGNOSIS
The client is diagnosed with major depressive episode with psychotic symptoms. Because he had
symptoms of depression (sadness, anger, feeling of sadness and hopelessness. Low on socialization
and self care) and psychosis – aggression, agitation, restlessness, delusions,social isolation, anxiety,
persecutory delusions etc.
TREATMENT PLAN
The psychiatrist is advised to his wife to take him to Civil hospital where he may be admitted for few
days to bring down his agitation. After that based on his progress medication and psychotherapies
will be advised.
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CASE STUDY- 2 (Moderate Obsessive Compulsive
Disorder)
Name: REHANA NAZIR
Age: 53
Marital status: widow
Gender: Female
Occupation: Housewife
Education: Graduate
Religion: Islam
Location of residence Kanth Bagh Baramulla
Socioeconomic status: Upper
Informant: Son
CHIEF COMPLAINTS
The client was reported to have forgetfulness. She worries a lot and get panic
very often. She washes her hands and perform her task very slow. She spends
most of the time in kitchen where she would keep washing utensils and cleaning
the floor of the kitchen. She also spends a lot of time in bathroom to bath and go
toilet. If any guest comes at home she gets panic.
HISTORY OF PRES ENT ILLNESS
The client has started to show the symptoms one year ago when she started to
forget things. she feels that something is falling (dust) so she washes hands
frequently. She has two sons .one of them is living separately with the wife and
other one got divorced and living with client. She worries a lot about his second
son. She reports that praying helps her a lot and she does not have any thoughts
of washing or cleaning at that time. Even though she was not much social but had
2 close friends with whom she used to meet but recently she has lost interest in
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everything and does not want to meet anyone. She has arthritis and she find it
difficult to do chores but cannot help. if guests come at home she gets panic.
Patient has arthritis and diabetes and no history of medical illness.
TREATMENT HISTORY
She takes medicine for arthritis and diabetes but for stress or anxiety she never took any help.
Sleep: does not sleep well
Appetite: Normal
Sexual interest and activity: NA
Energy: low
NEGATIVE HISTORY
No history of head injury, epilepsy, seizures, trauma, no elation of mood or
depersonalization or de-realization.
FAMILY HISTORY
There is no consanguinity between parents of the client. The client’s parents have
died. The client’s younger brother lives in same city. The client has 2 sons. One
of them is married and live separately whereas other son is divorced and live with
his mother.
FAMILY INTERACTION PATTERN:

The communication in the family is seen normal. There is good cohesiveness in
the family. There is seen negative expressed emotions from the family towards
the client.
PERSONAL HISTORY
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Birth order: first child
Birth and development history: normal delivery and milestones were achieved
on time, no childhood disorder present.
Behavior during childhood

Client shared good bond with her parents. In school she felt isolated and had low
self esteem. She had very few friends growing up. She was overweight and felt
that she is not as good looking as her cousin. As a result, she had low self
confidence. She was good in academic. Her parents encouraged her to focus on
household chores than study because it will be useful for him after marriage and
not her qualification.
Academic History:
The client was good in academic. However, she never participated in any social
activity because she thought she was overweight and people will make fun of
her. Her hobbies were reading and writing.
Occupational History:
No occupational history
Sexual History:
She shared good relation with her husband .and never had any romantic relation
other than her husband.
PRE-MORBID PERSONALITY:
The client is introverted, organized and systematic in nature. She finds it difficult
to talk with strangers. Client is very religious and prays 2 to 3 hours in a day.
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General appearance is neatly dressed, normal gait and gesture was present. Client
was overweight. The client has touch with the surrounding. Proper eye contact is
maintained. Rapport could be established with the client and there was positive
attitude towards the examiner. The client was comprehensive to simple rules from
the clinician and was cooperative for the session.

Slow psycho-motor movement is observed from the client.
SPEECH:
The speech was normal. Intensity and speed of communication of the client was
normal. There was no pressure of speech and it was coherent and goal directed.
MOOD / AFFECT:
● Subjectively: “I am anxious”,
● Objectively: the client is anxious and tired

The depth or intensity of mood is casual. The mood is stable. They are
congruent to the thought and communicable and appropriate to the
situation
THOUGHT:
Content: The patient has preoccupation of illness.
PERCEPTION:
No perceptual disturbances could be elicited from the client.
● The client is oriented to time, place and date
● Attention & Concentration is aroused and sustained
● Memory:
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Immediate
memory:
intact
Recent
memory:int
act Remote
memory:
intact
● Abstraction : intact
● General fund of knowledge: adequate
JUDGMENT:
Personal :
Intact Social
: Intact
INSIGHT:
The client has insight level of 6 which means she had true emotional insight.
INTERPRETATION:
Patient exhibited symptoms of OCD (obsessive compulsive disorder) . The client washes hands frequently
and worry about germs. Because of th is she is having difficulty working but still she cant help cleaning
because of the fear of germs.
TREATMENT PLAN:
She was advised do physical activity and relaxation.

Along with medicine she was advised to start counselling session
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CASE STUDY- 3 ( Bipolar affective disorder )
Name: MUDASIR ALI
Age: 26
Marital status: unmarried
Gender: Male
Occupation: Student
Education: BBA
Religion: Islam
Location of residence: Azad Gunj Baramulla
Informant: father and uncle
Reliability: Reliable and consistent but inadequate
CHIEF COMPLAINTS
According to the patient
“I have no problem. My mind is super fast and no one can match it.”
According to the informant
“he has become very aggressive and started abusing people. He had fights with his friends
and brother. He thinks that he is very intelligent and look down on others.”

The onset of the illness is acute. The client was apparently well a week ago. Three
days before he got to know that he cleared his entrance exam in IIM- Ahmedabad.
He had been very ecstatic about it. Later in the evening he got aggressive to his
younger brother who jokingly said that he may have cheated in entrance exams.
He responded him saying that his mind is super fast and he does not cheat like he
does.
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Next day while returning back home at bus station station he abused his best
friend and asked him to jump off in front of bus. he even tried to push him.
Next day he again abused his friend and got aggressive he kept repeating that no
one can match him. His father decided to bring him to the hospital. Currently
there is no significant change in his sleep pattern, he can maintain hygiene
however his energy level increased his appetite has decreased from past 2 days.
The patient does not have any kind of past illness/psychiatric illness Treatment History-
TREATMENT HISTORY
NIL
Sleep: client has not slept from 1 days
Appetite: decreased
Energy: very Active
FAMILY HISTORY
The patient family is a nuclear family. His father is a bank manager and brother
is doing his graduation. Family atmosphere is good. The patient financial status
is also good.
PERSONAL HISTORY
Birth order: first born, he has one younger brother.
Birth and development history:
-Birth history was normal, Birth cry was present, Birth weight 2 kilo,
Developmental milestones achieved before handed, no emotional or physical
problems were present in childhood.

The patient was good in school and used to score good marks. He had
many friends growing up and is an extrovert.
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Sexual history
Not elicited
Premorbid personality
The patient was extrovert and had many friends, he never showed any kind
of resistance earlier or aggressiveness
GENERAL APPEARANCE & BEHAVIOUR:

He was good wearing a check shirt and pant, hair was properly made well
dressed and groomed, Behaviour was restless was wringing his hands and the
patient was uncooperative, hyperactive, restless but well dressed. Attitude
towards examines- uncooperative, Rapport could not be established.
MOVEMENT AND BEHAVIOUR:

Agitation was present and the patient was constantly moving his hands.
SPEECH:
Rapid, pressure of speech was
observed productivity–high
Reaction time was decreased
MOOD / AFFECT:
Mood - irritable, euphoric
Affect- broad–congruent with mood
PERCEPTION:
No perceptual disturbances are seen from the client
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THOUGHT:
Content- Ideas of grandiosity, Form- flight of ideas, rapid thinking,tangentially

(where the patient does not come to the point)
● Memory:
Immediate
memory:
intact
Recent memory: intact Remote
memory: intact
JUDGMENT:
Personal :
Intact Social
: Intact
INSIGHT:
Level 1 - complete denial of the illness
INTERPRETATIONS:
The patient was diagnosed with bipolar affective disorder, current episode
hypomanic. The patient exhibited symptoms of increased energy and activity,
talkativeness, decreased need for sleep, irritability and currently experiencing
hypomanic episode.
TREATMENT PLAN:
He was prescribed mood stabilizers. He was asked to come after a week. Based
on his condition he will be given various psychosocial treatments such as
cognitive behavior therapy, interpersonal therapy etc.
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CASE STUDY- 4 (Moderate Depressive episode without somatic syndrome)
Name: REHAAN MUSHTAQ
Age: 16
Gender: Male
Occupation: student
Education: X std.
Religion: Islam
Location of residence Dewan Bagh Baramulla
Informant: Mother
Reliability: Reliable ,consistent and adequate
CHIEF COMPLAINTS
The boy is not interested in anything be his studies or any hobby. He keeps staring
at something. He was good in study until 9th Class but slowly became slow and
now his performance is very poor academically. He is not doing homework and
there are constant complains from school because of his aloofness and loss of
interest. He started crying a lot on small things and says that he is not able to
study then he gets angry and throw his books. His sleep is disturbed. he wakes
up at night feeling scared.

The client was good in studies until class 9th. But since one year he is not
performing well in school and stays aloof. His problem is intensified from last
2 months. He have been feeling hopeless and says that he cant study. He has
started crying a lot a trivial things. from last 2 days he is being aggressive and
irritated and has not gone to school. He was at his room from last 2 days.
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NIL
TREATMENT HISTORY
NIL
Sleep: disturbed
Appetite: decreased
Sexual interest and activity: NA
Energy: low
NEGATIVE HISTORY
No history of head injury, epilepsy, seizures, trauma, and no history of
repetitive thoughts and behaviors, firm beliefs, elation of mood.
FAMILY HISTORY
There is no consanguinity between parents of the client. The client is the middle
child. He as two sisters one elder and one younger. Clients parents are
overprotective since he is the only son in the family. 5 years back he got dengue
after that his mother is overly protective of him and does not allow him to got
out and play.
FAMILY INTERACTION PATTERN:

The communication in the family is seen normal. Mother looked very concern.
Decisions in the family is headed by the husband with the consent of everyone
in the family. There is good cohesiveness in the family. There is not seen
negative expressed emotions from the family towards the client
PERSONAL HISTORY
Birth and development history: normal, no birth disorder.
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Academic History:
The client was good in studies. But before one year he has started loosing
interest and get low marks.
PRE MORBID PERSONALITY:

Client was introvert. he was good in studies. He had good friends but
recently not going out to meet them. His hobby is painting and drawing .

General appearance is neatly dressed, normal gait and gesture was present.
The client has touch with the surrounding. Lack of eye contact observed. The
client was comprehensive to simple rules from the clinician and was
cooperative for the session.

slow psycho motor movement is observed from the client.
SPEECH:
The speech was normal. Intensity and speed of communication of the client
was normal. There was no pressure of speech and it was coherent and goal
directed. MOOD / AFFECT:
● Subjectively: “I am sad”,
● Objectively: the client was sad and tearful

THOUGHT:
Content: The patient has preoccupation of illness.
PERCEPTION:
No perceptual disturbances could be elicited from the client.
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● Memory:
Immediate
memory:
intact
Recent
memory:
intact
Remote
memory:
intact
● Abstraction: intact
● Judgment: Intact
INSIGHT:
The client has insight level of 5 which means client has intellectual insight.
INTERPRETATION:
Moderate depressive episode without somatic syndrome. Client exhibited symptoms of hopelessness,
sadness, cries a lot, isolation etc.
TREATMENT PLAN
Doctor had prescribed him Antidepressant. He had asked him to come after 1 weeks. Doctor strongly
advised to go for counselling. clearly he had symptoms of depression cause of which is unknown
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CASE STUDY- 5 ( Child Behavioral Issues )
Name: SAIMA MAJID
Age: 6.8
Gender: Female
Occupation: Student
Education: LKG
Religion: Islam
Location of residence Janbazpora Baramulla
Informant: Mother
NEONATAL HISTORY
● 1st in birth order
● Cesarean and Full- term delivery
● Immediate birth cry
● No complications during pregnancy
● Normal health and weight of the child during birth
CHIEF COMPLAINTS

“She has become very sensitive and gets scared easily.”

The She gets angry easily since she was 1year old. This behaviour is getting worst
day by day as she cries a lot as well as she is moody regarding completing any
task. If she does not want to do something she will not do. She cries for approx
1/2 an hour or longer periods until her mother soothes her.
She feels she should come first that makes her more scared and worried. She has
oversensitive nose.
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The patient does not have any kind of past illness/psychiatric illness Treatment History
TREATMENT HISTORY
NIL
Sleep: Normal
Appetite: Normal
Energy: Very Active
FAMILY HISTORY
The c l i e n t family is a nuclear family. H e r father is a A dvocate and m

other is N u t r i t i o ni s t . Family atmosphere is good.
PERSONAL HISTORY
Birth order: First born.

Birth history was normal, Birth cry was present, Birth weight 2.8kg, Developmental
milestones were achieved on time.
Behavior :
The client is good in school and chief complaints from teachers are that she is
talkative.
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ESTABLISH RAPPORT

She was good wearing a t shirt and pant, hair was properly made well dressed and
groomed, Behaviour was restless was wringing his hands and roaming here and
there. The client was uncooperative, hyperactive, restless but well dressed.
Attitude towards examines -uncooperative , Rapport could not be established

Agitation was present and the the client is so active, didn’t sit properly. No instruction is being
followed by her.
SPEECH:
Rapid, not that much clear.
MOOD / AFFECT:
Mood - irritable, Stubborn.
PERCEPTION:
No perceptual disturbances are seen from the client.
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THOUGHT :
Content- Lack of concentration, stubborn.
COGNITIVE FUNCTIONS :
● The client is little oriented to time, place and date
● Attention & Concentration is little bit.
● Memory: intact
JUDGMENT:
She is too young for it.
INSIGHT:
As she is just 6.8years old, don’t have any insight.
PROVISIONAL DIAGNOSIS
The client was diagnosed with behavioral issues.
INTERPRETATION:
The detailed case history and psychological assessment reveals that the child has above average level
of intelligence on Seguin form board. On Vineland social Maturity Scale, which assesses social
intelligence, the child has above average social quotient, which reflects good social maturity.
RECOMMENDATIONS:
● Therapist is recommended to improve his BEHAVIOURAL ISSUES to provide CBT.
● Psycho education to parents is needed to understand and modify their parenting skills.
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CASE STUDY- 6 ( Generalized Anxiety Disorder )
Name: NUSRAT JAN
Age: 28
Gender: Female
Occupation: Govt. job
Education: Graduation
Religion: Islam
Location of residence Sopore Baramulla
Informant: Self
CHIEF COMPLAINTS
According to the Client:
● Anxiety
● Lack of energy
● Miner issue is very triggering crying and aggressing
● Head heaviness (Duration of course)
● Tension , shivering in hand and mile sweat
● Stress, suicidal thought
She is teaching in an organization but now she don’t like going. She took one
week off from last to last week. I was working there from 5-6 years, due to such
old relations , it wouldn't bother them but otherwise she would have lost her job.
6months back her grandfather died. She got engaged to his boy friend with whom
she is in a relation with him from past 8 years and due to long distance she broke
up for 2 years. Now as the date of marriage is getting close, she has getting panic.

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The patient does not have any kind of psychiatry issue but have medical history.
● Thyroid 2013-14
● PCOD 2013-14
● Surgery : 2 time (2018)
TREATMENT HISTORY
Took medicines like
Thoronome 88 daily 1time and Obmet SR500 Twice in a day.
Sleep: Improper
Appetite: decreased
Energy: Inactive
FAMILY HISTORY
The c l i e n t ’ s family is a nuclear family. Her father and mother is doing govt.
job and y o u n g e r brother is doing his graduation. Family atmosphere is good.
The client’s financial status is average.
PERSONAL HISTORY
Birth order: first born, he has one younger brother.
-Birth history was normal, Birth cry was present, Birth weight 2 kilo,
Developmental milestones achieved before handed, no emotional or physical
problems were present in childhood.

The patient was good in school and used to score good marks. He had
many friends growing up and is an extrovert.
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Sexual history
Not elicited
The patient was extrovert and had many friends, she never showed any kind
of resistance earlier or mood swings.

She was salwar suit, hair was properly made well dressed and groomed,
Behaviour was restless was wringing his hands and the patient was
uncooperative, hyperactive, restless but well dressed. Attitude towards
examines- cooperative.

Client is too worried about future and her marriage.
SPEECH:
Slow and tensed.
Reaction time was decreased
MOOD / AFFECT:
Mood - irritable, euphoric
Affect- broad–congruent with mood
PERCEPTION:
No perceptual disturbances are seen from the client
THOUGHT:
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Content- Have distorted thoughts, giving too much stress on her future
● Memory:
Immediate
memory:
intact
Recent
memory:
intact
Remote
memory:
intact

JUDGMENT:
Personal :
intact Social
: intact
INSIGHT:
Have full insight of her illness.
INTERPRETATION
The detail psychometric assessment reveals that client has moderate level of Anxiety.
RECOMMENDATIONS
● The client needs therapy sessions for her diagnosis.
● Some mindful exercises are too recommended.
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CASE STUDY- 7 (MILD Level of Depression)
Name: NUSRAT JAN
Age: 28
Marital status: Unmarried
Gender: Male
Occupation: Govt. job
Education: Graduation
Religion: Islam
Location of residence Kanispora Baramulla
Socioeconomic status: Middle Class
Informant: Self
The information is adequate, reliable and consistent
CHIEF COMPLAINTS
‘Since last year, I have been feeling I have depression symptoms. I have not attended even a single
class in the last semester and I know I am behind and it’s important. I sleep late and get up late. I feel
lazy all the time; I only get up to eat, sometimes not even then. But when I do eat I eat a lot.’
Predominant symptoms:
1. Feeling ‘depressed’
2. Lethargic, not attending any class or participating in any form of exercise
3. Increased sleep and eating Onset: Sub-Acute
4. Course:Continuous Progress:Deteriorating
5.
The client joined IIT 2 years ago after completing high school. He expected his college life to be easy
going and was looking forward to making friends and spending time with them. However, in his very
first day the client was intimidated by the cultural change and the academic pressure, wherein he felt
that he had a lot of catching up to do. In his 1st semester, he suffered from a fractured leg due to which
he had to stay at home for 40-45 days. By the time he got back, he realised everyone had settled in and
he felt out of place. This also built up the academic pressure on him. The client never fully recovered
and got back on his feet as in the 2nd semester itself, he began to miss classes and fall behind.
HISTORY OF PAST ILLNESS
(Unclear) The client faces some problem in his sex organs that probably prevents him from forming
intimate relationships. This information was shared briefly by his father; the client never reveals the
same.
Biological Functioning Sleep: Increased Energy: Decreased Appetite: Increased
Sexual Life: Non existent
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Psycho social History
Social and Developmental History
The client was living in the hostel of IIT, Delhi. However, on recognition that he requires constant support, his father
has now shifted with him to an apartment in Delhi. Living in the hostel, although he had a roommate, the client spent
his days alone in his room, sleeping, eating or spending time on his laptop. He barely attended any classes since the
2nd semester. The client expressed that he enjoys studying mathematics, however, his current profession he does not
understand very well. His reason for getting into IIT was that he was unaware of any other career line. He is also
interested in football and follows all matches religiously. The client does not have many friends and is not a very
social person. He has a few friends from school whom he is still in touch with. However, he rarely ever shares his
problems or troubles with anyone.
The client has been unable to recall many childhood incidents. The few he did recall were positive ones, wherein he
was being given something or being helped by someone.
Family and Sexual History

The client describes his family being always supportive and his relationships with everyone as ‘good’. He has an
elder brother who is working and is in a similar field of work. While his brother was studying, he could not get a
good rank to get into a prestigious institution. The client who witnessed this could see that his father was
disappointed by it. The father describes the client’s relationship with
his brother as being very close, almost inseparable when they are at home together. However the client does not
share his view and says that his relation with his brother is cordial. They get along but are not in touch often. The
client seems to have difficulty talking about his nature of relationships.
The client has never dated anyone or pursued any love interest. He does not even have female friends
Educational History
Academically the client has always performed very well. He was in 9th when his father was disappointed by his
brother’s performance and the client felt it was his ‘responsibility’ not to disappoint him as he has made so many
sacrifices for them and their education. In 10th the client chose non-medical as his stream as he was told that
commerce is for those who cannot study and humanities is for losers. The only option he was left was non-med as he
also loved math. In 11th standard, the client spent most of his time with his. Fiends and ended up scoring low marks.
Thus, 12th onwards the client started devoting 9-10 hours daily to his studies. He enjoyed studying but was also
frustrated by the end. His parents did not notice this change in routine as if not studying; he would anyway spend his
time sitting alone in his room on the laptop.
The client also managed to clear his entrance examination and get into IIT which made his parents proud. It was
college life that led to a dip in his academics. Missing classes and unexpected academic pressure that made it
difficult for the client to cope
Mental Status Examination
General Appearance: Gait: Normal towards obese Posture: Balanced Clothes, grooming and hygiene: Well-attempt
(have been informed that he does nor bathe/change his clothes for days together)
Behaviour Psychomotor activities: Normal Expression: Constricted
Eye contact: Not maintained Mannerisms: Absent Gestures: Normal Compulsions:
Absent Orientation to time, place and person: Oriented
Attitude: Cooperative
Speech and language Volume: Low
Tone: Normal Tempo: Slow

Reaction time: Decreased Spontaneity:
Absent Content: Poverty Prosody: Absent Articulation: Good Articulation Relevance: Present
Thought:
Form Logical: Present Organised: Present Systematic: Present Coherence: Present Stream: Circumstantial
Possession: Absent Content: Adequate
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Mood and Affect Subjective: ‘I am fine.’ Objective: Depressed Range: Constricted Expression: Constricted
Reactivity: Present
Relevance to thought: Congruent Situation: Appropriate Intensity: Moderate
Perception: No perceptual disturbances.
Cognitive functions: Not tested but no problems detected

Insight: Grade III: Awareness of problems but does not know the reason or what to do to get better.
Treatment and Interventions
Client’s internal dialogue represented his want to teach and learn Math had he been independent of his parents and
feeling guilty for not attending classes
Sentence Completion:
Hard working Self conscious

Worried about his future Body image issues Feeling lonely
Low self-esteem
Lack of emotional connections and bonding Emotion Focused Therapy

Message: ‘Even though I find it difficult, it is important for me to go to college and be regular
INTERPRETATION:
The detailed mental status examination and psychometric assessment reveals that he has low self esteem, poor
interpersonal relationship and adjustment issues. He is concerned about his body image. He has been facing difficulty
in expressing himself and trusting others, too. He seems to be facing conflicts with the opposite gender also. Even
though he is hardworking and concerned about his future too, but his poor coping skills and over thinking might have
led him to a mild depression. He experiences loneliness, anxiety and at time, gets aggressive too.
The subject, being introvert, never shares his inner conflicts with anyone. Moreover, not wanting to hurt anyone, he
keeps his feelings and emotions to himself. He has supportive parents but they do not get the space to enter his
feelings. He has a great many conflicts concerning life goals, male and female friends and inter- and infra-personal
relationships.
Various psychological therapies like Cognitive Behaviour Therapy, Emotional Freedom Therapy, Rational Emotive
Therapy and Jacobson’s Progressive Relaxation Therapy and Family Counselling administered to him have shown
good results. Consequently, he has begun expressing his feelings and emotions and has started making friends, too. It
appears that now he is in a position to re-join the Institute and do well in academics.
RECOMMENDATIONS
Psychotherapy
Counselling for maintaining a balance between academic and personal life.
35
CASE STUDY- 8 (AUTISM SPECTRUM DISORDER)
Name: MEHAK JAN
Age: 3.6
Marital status: NA
Gender: Female
Occupation: Student
Education: Playway
Religion: Islam
Location of residence Noor Bagh Baramulla
Informant: Mother
NEONATAL HISTORY
● Conceive at the age of 36 years
● Cesarean delivery
● No medication during pregnancy
● Birth weight 3.2 KG
CHIEF COMPLAINTS
According to the informant (Mother)
◆ Stubborn
◆ Aggressive
◆ Doesn’t listen
◆ Communication issues
◆ Poor sentence formation

She is so stubborn and gets angry easily since she was 1year old. She is delayed
in speech from childhood. She is not reacting to her name. She doesn't
communicate well. Poor eye contact is also an issue from the beginning.
39
TREATMENT HISTORY
NIL
Sleep: Normal
Appetite: Normal
Energy: Very Active
FAMILY HISTORY
The c l i e n t family is a nuclear family. H e r father is a P h a r m a c i s t and

m other is H o u s e w i f e . Family atmosphere is good.
PERSONAL HISTORY

Birth history was normal, Birth cry was present, Birth weight 3.2 kg,
Developmental milestones were achieved on time but delayed in speech.
Behavior :
She is so aggressive and irritable in nature. She is so restless and she has very
poor eye contact and even after calling her name, she is not able to respond to
that.
58
40
ESTABLISH RAPPORT
Dhariyaa who is 3year and 6 months old girl, dressed simple with loose clothes, she always
making some noise and make able to talk with her mom clearly. I gave her a small toy scooter ,
she just try to see his wheels and then i asked to her mom that is she is attracted towards any
spinning and revolving things and she said yes. She used to see fan and car wheels a lot. Then i
started taking full case history and side by side i was trying to catch the behaviour of dhairya.
She has very poor eye contact and even after calling her name, she is not able to respond to that.
While asking her case history i came to know she was delayed in speech too.
● repetition in words
● restless
● gets distract easily
● difficulty in comprehension
SPEECH:
Messy, not understandable, repetition of words.
MOOD / AFFECT:
PERCEPTION:
41
THOUGHT :
NA
JUDGMENT:
INSIGHT:
As she is just 6.8years old, don’t have any insight.
intelligence below 11 years to form an idea about mental ability.
INTERPRETATION
The detailed case history and psychometric assessment reveals that child falls in mild level of Autism
Spectrum Disorder; Moderate level of social quotient and has average level of intelligence. From
observation it was observed that she has poor eye contact; she often repeats words; she has rigid behavior
and is stubborn
RECOMMENDATIONS
Therapist is recommended to improve his speech, fine motor skills and social skills.
Psycho education to parents is needed to understand child’s disorder and modify their parenting skills
42
CASE STUDY- 9 (Psychological Assessment)
Name: BISMA RAMZAN
Age: 6.3
Gender: Female
Occupation: Student
Education: KG
Religion: Islam
Location of residence Khawaja Bagh Baramulla
Informant: Mother
NEONATAL HISTORY
● 1st in birth order
● Normal and Full- term delivery
● No complications during pregnancy
● Normal health and weight of the child during birth
● All milestones were delayed.
CHIEF COMPLAINTS

“He is aggressive in nature and emotional vulnerable so school teachers suggested for
psychological assessment”.
When he was 2 year old, he used to throw his toys and break them so his mother
scolds him a lot. Then he become so much attention seeker. As both of the parents
are working so time given to him is less in number.
66
45
TREATMENT HISTORY
NIL
Sleep: Normal
Appetite: Normal
Energy: Very Active
FAMILY HISTORY
His father Mr. Rajesh Chadha has completed his MBA and currently working as
AVP in Tata AIG Insurance, Mumbai and his mother Mrs. Anupriya Chadha has
completed her MCA, B.Ed and is a housewife. No one has any Psychological
issue.
PERSONAL HISTORY

Birth history was normal, Birth cry was present, Birth weight 2.5kg, Developmental
milestones were delayed.
Behavior :
He is aggressive in nature and fights with others while playing games. Looks
disturbed from inside. Cries on every small things.
46
ESTABLISH RAPPORT

He is wearing simple t-shirt and jean but not in a proper manner, as the jean is
too loose from waist. The client was uncooperative, hyperactive, restless.
Attitude towards examines -uncooperative , Rapport could not be established

He continuously doing something, always try to pick anything from the table.
SPEECH:
Rapid, not that much clear.
MOOD / AFFECT:
PERCEPTION:
THOUGHT :
● The client is little oriented to time, place and date
● Lack of Attention & Concentration
● Memory: intact
68
47
JUDGMENT:
INSIGHT:
As He is just 6.8years old, don’t have any insight.
PROVISIONAL DIAGNOSIS
The client was diagnosed with behavioral issues.
DRAW A FAMILY:
The Draw a family is a psychological projective personality or cognitive test used to evaluate
children and adolescents for a variety of purposes.
The figures on Draw a family test reveals that the child is/ has :
● Insecure/ Helpless
● Feeling of Rejection
● Emotionally Vulnerable
● Inhibition
● Poor Self Image
● Aggression
● Ambivalent
● Trust Issues
● Poor Self Concept
● Lack of power/feels ineffective
INTERPRETATION:
The detailed psychometric assessment reveals that the subject result on CPM shows Intellectual
Deficiency. Mild level of Social quotient on Vineland Social Maturity Scale and Borderline level
of intellectual functioning on Seguin form board. His results on Draw a Family Test depicts that
he feels insecure, has poor self concept, has sense of guilt, inhibition. He finds difficulty in
trusting others.
48
RECOMMENDATION
● Special educator/ Shadow teacher in school for individual attention

● Short Instruction Period.
● Minimize distraction in classroom.
● Teach in Small Groups.
● Use few and simple words and maximize demonstrations.
● Use peer Partner.
● Provide Opportunities for choice of activities.
● Emphasize range of motion exercises.
● Allow for periods of rest during Instruction.
● Reinforce and use multi sensory approaches.
● Provide prompt and consistent feedback
● Check for skill retention often.
● Offer activities that provide initial success.
● When appropriate put in leadership goals.
● Systematically ignore inappropriately behavior, model appropriate behavior and practice
appropriate behavior and responses
49
CASE STUDY- 10 (Claustrophobia)
Name: AJAZ AHMAD
Age: 55
Marital status: Married
Gender: Male
Occupation: Businessman
Education: 12th pass
Religion: Islam
Location of residence Delina Baramulla
Informant: Brother
CHIEF COMPLAINTS
According to patient
“Whenever I am in crowd or I think about being in crowd then I feel uneasy
and get sensation of cold feet and hands. I feel like I will die”
“I have problem to be in closed places like lifts and planes. But I also feel anxious when I am
alone at home.”
Informant states that
“His condition is causing a lot of distress to his family and they are ready to do anything to get
him treated”
Five years ago the patient had started showing symptoms of anxiety and panic
attacks. he would have such attacks when he is in closed space or is alone at
home. He would experience racing hearts, cold hands and feet, chest pain,
difficulty breathing and palpitation. He thought he had heart problem. As a result,
he had many physical examinations like ECG etc. But everything came out
normal. He had gone to many doctors for treatment including homeopathy,
naturopathy
52
etc. Six months back he was alone at home and fainted in bathroom after panic attack as a
result general physician advised him to see a psychiatrist.
He has travelled all the way from Jaipur to see a psychiatrist. Since he is afraid of travelling in
plane he came by train whereas his brother came by plane. He feels that lift will be closed and
he will be stuck in lift. He also experiences anxiety before sleeping and live in fear that he may
have attack any time as a result he feels stressed and restless most of the time which is causing
a lot of distress to family as well. He is the only breadwinner of the house. he has done treatment
from many doctors but nothing helped.
Mode of onset: Insidious
Course of illness: Fluctuating
Progress of illness: Static
Duration of illness: 5 years
Predisposing factors: Being in closed places or
alone at home
limiting factors: When patient goes to open space,
deep breath, rub his hands and drink
water
Associated disturbance: lack of sleep, restlessness and stress
perpetuating factors: anxiety in psychological factors
NIL
TREATMENT HISTORY
Patient is currently not taking any medication. But in the past he had gone to many doctors to
treat his physical symptoms but nothing had helped him.
Sleep: client is not sleeping well from two weeks.
Appetite: normal
Energy: Active
74
53
NEGATIVE HISTORY
There is negative history of heart disease, high blood pressure and diabetes
FAMILY HISTORY
There is no consanguinity between parents of e client. The client’s mother is a housewife and
his father has retired from his business as he is not keeping well. He has two elder brother and
they share a good bond. The client has one son who is pursuing his higher education from USA.
PERSONAL HISTORY
Birth and development history: Not available
The client stated that he had always been anxious growing up. He used to worry a lot during
exams and would not be able to sleep and eat properly. He used to be introvert child and had
trouble talking with strangers. He described himself as a shy person. He didn’t have many
friends but he shared close bond with few people.
Academic History:
Client is 12th pass. He didn’t have much interest in studying as a result he joined his family
business after 12th class. He liked playing cricket when he was in school.
Sexual history
Not available
54
The client is introverted and anxious person. He is spiritual. he has difficulty bonding with
people.

Appearance is neatly dressed. The client has touch with the surrounding. Gait and gesture is
normal. Rapport could be established and has a positive attitude towards examiner.

The psycho motor movement is normal.
SPEECH:
Speech is normal. The intensity / Tone is normal and Productivity also normal. The client’s speech
is coherent and goal directed. His speed is normal and there is no pressure or poverty of speech is
observed.
MOOD / AFFECT:
● Subjectively: “I am worried”
● Objectively: The client is concerned about his health.

The depth and the intensity of the affect is normal. Mood is observed as congruent to the
thought, communicable and appropriate to the situation.
THOUGHT:
● Content- the client had preoccupation about fear of closed spaces.
PERCEPTION:
No perceptual disturbances is seen from the client
76
55
● Memory:
Immediate memory:
intact Recent memory:
intact Remote
memory: intact
● Abstraction:
Similarities:
adequate
Differences:
adequate Proverb:
adequate
● Judgment:
Personal:
intact
Social :
intact Test:
intact
JUDGMENT:
o Personal:
o Social: Intact
o T
est: INSIGHT:
Level 6- true emotional insight: emotional awareness of the motives and feelings of illness
which leads to changes in behavior or lifestyle
DIAGNOSIS
The patient was diagnosed with Claustrophobia F40.2. The patient exhibit symptoms of
hot flashes, panic attacks, tension, sweating, nausea and fainting.
56
TREATMENT PLAN
The client was prescribed medicine to reduce the symptoms of anxiety. He was advised to start psychotherapy as soon as
possible. Doctor advised him to come again after two weeks
In the first column he was asked to write about the situation which makes him feel anxious. In the second column he was asked
to write the negative emotions he was feeling from a scale of 0 to 100. In third column, to identify his automatic negative
thoughts and images which comes to his mind when he thinks of using lift. In fourth column, write his real thoughts and
evidence which supports his thought. In fifth column client wrote to introspect other perspective followed by evidence which
support the new perspective. At the end when client was asked about his feeling he gave score of 60, which is a significant
improvement from 90. We ended the session with the client and asked him to come after a week.
FUTURE TREATMENT PLAN
Future treatment plan is to give exposure therapy to client after a couple of sessions. It s a type of behavioral therapy that is
designed to help people manage problematic fears. Through the use of various systematic techniques, a person gradually exposed
to the situation that causes them distress. The goal of exposure therapy is to create a safe environment in which a person can
reduce anxiety, decrease avoidance of dreaded situations, and improve one's quality of life.
Psychologist is focused to give systematic desensitization technique to client. It is a technique incorporates relaxation training,
the development of an anxiety hierarchy, and gradual exposure to the feared item or situation. The relaxation training might
include progressive muscle relaxation and guided imagery. The anxiety hierarchy might use something like Wolpe's Subjective
Units of Discomfort Scale (SUDS) to create a list of anxiety-producing events on a scale from 0-100. Then, during the gradual
exposure to the ranked items, the learned relaxation techniques are applied to offset stress and anxiety
57

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CASE STUDY- 1 (Severe depressive episode with psychotic symptoms)

PAST PSYCHIATRY AND MEDICAL HISTORY

Client does not have any prior psychiatric or medical history

PRE MORBID PERSONALITY:

ALCOHOL AND SUBSTANCE HISTORY:

GENERAL APPEARANCE & BEHAVIOR:

Form of thought disorder: absent

● oriented to time, place and person.

Personal : Impaired Social

HISTORY OF PRES ENT ILLNESS

PAST PSYCHIATRY AND MEDICAL HISTORY

Patient has arthritis and diabetes and no history of medical illness.

FAMILY INTERACTION PATTERN:

Behavior during childhood

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE & BEHAVIOR:

MOVEMENT AND BEHAVIOR:

● Objectively: the client is anxious and tired

Content: The patient has preoccupation of illness.

No perceptual disturbances could be elicited from the client.

● The client is oriented to time, place and date

● Attention & Concentration is aroused and sustained

● General fund of knowledge: adequate

She was advised do physical activity and relaxation.

According to the informant

HISTORY OF PRESENT ILLNESS

PAST PSYCHIATRY AND MEDICAL HISTORY

Behavior during childhood

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE & BEHAVIOUR:

MOVEMENT AND BEHAVIOUR:

Reaction time was decreased

Affect- broad–congruent with mood

Content- Ideas of grandiosity, Form- flight of ideas, rapid thinking,tangentially

● Attention & Concentration is aroused and sustained

HISTORY OF PRESENT ILLNESS

FAMILY INTERACTION PATTERN:

PRE MORBID PERSONALITY:

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE & BEHAVIOR:

MOVEMENT AND BEHAVIOR:

● Objectively: the client was sad and tearful

● Attention & Concentration is aroused and sustained

● General fund of knowledge: adequate

● 1st in birth order

● Cesarean and Full- term delivery

● Immediate birth cry

● No complications during pregnancy

● Normal health and weight of the child during birth

According to the informant

HISTORY OF PRESENT ILLNESS

The c l i e n t family is a nuclear family. H e r father is a A dvocate and m

Birth order: First born.

GENERAL APPEARANCE & BEHAVIOUR:

MOVEMENT AND BEHAVIOUR:

Rapid, not that much clear.

Content- Lack of concentration, stubborn.

● Attention & Concentration is little bit.