CASE

CONFERENCE

Presenter: Simran Raina Sharin Chairperson: Ms Shivangi Agrawal

PDCP Associate Professor
Department of Clinical Psychology Department of Clinical Psychology
 AIM OF THE
PRESENTATION
1. To seek diagnostic clarification of the psychopathology of the index patient.

2. To discuss the management plan.

SOCIO-DEMOGRAPHIC DETAILS
Name A.S.

Age 26 years

Sex Male

Educational Qualification Graduate

Marital Status Unmarried

Socio-economic status Lower Middle Class

Address Delhi

Occupation Employed

Referred by Self-referred

Reason for Referral Psychotherapy Intervention

INFORMANT DETAILS
Unavailable – ( The patient does not want to involve his family)
The information provided is reliable and partially adequate.
 CHIEF COMPLAINTS (by patient)
“Bahut gussa aata hai, bahut zyada Khud ko maarne lagta hu, baad
mein regret hota hai”
Since
childhood

“baar baar papa ki wahi baatein dimaag mein ghumti hain aur sunayi
deti hain, har waqt wo tokte rehta hain”

“Bahut chota feel karta hu, jaise peeche reh gya, jo sab hua uski
wajah se meri development jaise ruk gayi ”

For the past 3

“Sab ke saath problems ho jati hain, ghar pe, friends ke saath, office
mein, bahut akela feel karta hu” years

“baat karte waqt ankhon ke saamne aata hai sab pehle ka”
“Lagta hai sab mere baare mein baat karte hain”
 ILLNESS SPECIFIERS

Onset: Course: Progress:

Insidious Continuous Deteriorating

Perpetuating Factors:
Precipitating Factors:
Predisposing Factors:
• Maladaptive/Negative
 Uncongenial home • Physical abuse by father thoughts
environment • Temperament (choleric)
• Poor social network
 History Of Presenting Illness
The patient was asymptomatic untill the prolonged physical, verbal, and emotional abuse he endured from his father
during his developmental years. This trauma included incidents of being strangled and repeatedly punched in the face,
resulting in intense feelings of rage and resentment, described as "bahut gussa aata tha aise chid machti thi" the
patient experienced intense feelings of anger and irritation that led to the development of affect dysregulation in
other areas of life. The patient struggles to control his impulsive behaviour and unpredictable outburst.
His father's abuse extended to forcing the patient to take early morning baths at 4 a.m., regardless of the weather,
while allowing his older brother to sleep peacefully. This created a sense of being targeted and helpless. In one
instance, the patient was asked to fetch his elder brother from playtime and was then barred from entering the house.
When he questioned this, he was struck on the head with a rod, causing severe bleeding and requiring immediate
medical attention. The patient expressed confusion and distress about the incident, saying, "mujhe bahar jana mana
tha aur bhai jata tha, mere ko kyun maara, maine kya kiya tha“. Such incidents led to disturbances in self
organization which includes negative self-concept as being diminished and worthlessness.
The patient also witnessed regular episodes of domestic violence which left him with feelings of anger and
powerlessness. He understood that his mother could not protect him from his father's wrath because she, too, was a
victim: "wo kaise bachati, unko bhi papa maarte the“, this made him feel ashamed and guilty as he took it as his
personal failure which culminated into poor self-esteem and social skills deficits.
 History Of Presenting Illness
In November 2020, following his father’s death, the patient began hearing his father's voice commanding him and
interfering with his everyday actions as before when he was alive. He reported hearing his voice throughout the day
following him everywhere in the house once telling him during a meal, “arrey bas kar, aur kitna khayega”, which made
him angry and irritated like before, these intrusive flashbacks perpetually puts him into a state of hyperarousal
including startling responses to trivial events around him leading to everyday interpersonal conflicts.

The patient reported while re-experiencing these past traumatic incidents he is immersed in the same strong and
overwhelming emotions of anger, irritation and shame accompanied with bodily reactions including teeth-grinding and
fist-tightening that were experienced during the traumatic events.

In 2022, the patient had an argument with his two childhood friends pertaining to his exclusion from social plans
initially made by the three of them. Upon confronting, he failed to convince them of his perspective, exacerbating his
frustration, confusion and anger. He severed communication with them for over a year, stating, “main convince nahi
kar pata hu aur wo sahi ho jaate hain mujhe galat prove kar ke, ye soch kar bahut gussa aata hai”, exhibiting
persistent difficulties in affect regulation and maintaining relationships.
 History Of Presenting Illness
This led to intense feelings of loneliness, the patient reported that whenever he is alone in his room he makes
conversations with friends and acquaintances, cracking jokes and making them laugh. His interactions are apparently so
real that often his mother enquires whom he was speaking to: “yeh kisse baat karta rehta hai”. Similar incidents occur
at work where his colleagues observed him smiling to himself while sitting alone, asking, “ye kahaan khoya rehta hai,
kiske saath hansta rehta hai” exhibiting inability to sustain connections thereby coping in a maladaptive manner.

While coping with these struggles, the patient was befriended by a female coworker in July 2023. He felt happy and
special about how she treated him, describing their relationship as romantic. However, he later discovered she is in a
relationship with another man for the past four years. Upon confronting her, she initially denied, leading to multiple
conflicts between them. Eventually, she acknowledged his accusations and apologized, but the patient felt her apology
lacked sincerity. This left him deeply hurt and preoccupied with repeated intrusive thoughts about their relationship,
stating, “mere bolne pe sorry bola usne khud nahi bola, wo tho maan bhi nahi rahi thi ki uski koi galti hai “. The
patient often calls her to accuse and humiliate her even after months of their break-up exhibiting feelings of
heightened emotional reactivity, anger outburst and emotional dysregulation.
 History Of Presenting Illness
In February 2024, the patient had a verbal altercation with his mother over rituals and dietary restrictions. Although he
was adhering to the rules, his mother’s repeated instructions triggered old, distressing memories of his deceased father
resulting in sudden anger outburst, banging his head on an iron box and slapping himself repeatedly. The patient
reported that his anger issues were increasing in frequency and intensity overreacting to trivial matters, often resulting
in self-harm, “bahut gussa aata hai har ek baat par, khud ko bhi maarne lag jaata hu”.
He further reported symptoms of depression including feelings of worthlessness, hopelessness and low mood. He
further reported having fleeting thoughts of death-wish.
The patient also noted difficulties with attention, organizing, and planning tasks, which have impacted his work
performance. He reported, "ab kaam mein mann nahi lagta, kuch organize nahi kar paata hu, irritation se hone lagti
hai. He reported memory issues, particularly related to tasks assigned by his mother, stating, "mummy jo bhi kaam deti
hai, main roz bhool jata hu”.
On February 2024 during the session patient was extremely guarded while responding to questions regarding the
trauma, he grinded his teeth and gave a warning glare to never speak about his father exhibiting extreme avoidance of
conversation about the trauma.
These growing feelings of anger and loneliness motivated the patient to seek help at SGT hospital.
BIOLOGICAL FUNCTIONING

SLEEP: Difficulty falling asleep.

APPETITE : Adequate.
ENERGY : Adequate
SEXUAL ACTIVITY : No abnormalities reported
 Negative History
No history suggestive of significant head injury, loss of consciousness, high grade fever and epilepsy/seizures.

No history suggestive of harmful use of alcohol or any other psycho active substance.

No history suggestive of seeing images that don’t exist and abnormal tactile sensations.

No history suggestive of elevated mood, increased energy, inflated self-esteem and increased talkativeness.

No history suggestive of impulses or any repetitive behaviour. No history suggestive of intense fear of specific
object or situation.

No history suggestive of partial or complete loss of the normal integration of memories, awareness of identity
or control of bodily movements.
 TREATMENT HISTORY

History of Psychiatric Illness/ treatment:

In 2022 the patient reported visiting Psychiatry History of Medical Illness/ treatment:
department at SGT with complaints of anxiety
where he was prescribed medications. The patient
reported non-compliance of medications due to None reported
fear of dependency.
MEDICATIONS

In 2022
Nexito
5 mg * 1 month
10 mg * 1 month
15 mg * 1 month
 Family History
No consanguinity was reported between the parents. The parents shared a hostile relationship including domestic
violence and poor social network. The patient reported his deceased father was an aggressive person who abused both
him and his mother. He had no social network and was lonely through his life. When the patient was 5 years old his father
went missing from home for 2 years and was later found in Bihar jail with a broken leg. He was safely brought back home
with the help of patient’s maternal uncle. The patient also reported that his brother also exhibits aggression and often
harms himself during anger outburst.

Family History of Medical Illness: Nil contributory

Family History of Psychiatric Illness: Father and brother exhibit aggression and self harm during anger outbursts.
Family Genogram
 Personal History
Birth History: Unavailable

Early Developmental History: Unavailable

Childhood History: The patient reported that he was physically, verbally and emotionally
abused by his deceased father including unreasonable vigilance inhibiting the development
of a healthy social network for the patient. When the patient was 8 years old he was sent to
live with his maternal aunt for a year owing to financial difficulties at home. The patient
grew up traumatized with predominant feelings of anger, resentment, insecurity and
irritability making him socially inept to form relationships and maintaining them.

Home atmosphere: The patient grew up in an uncongenial environment which included

violence and abuse. The patient’s father was a troubled man with anger issues and had no
social network. The patient’s elder brother also exhibits aggression including self harm
during anger outbursts.
 Personal History
Scholastic and Extra-curricular Activities: The patient started going to school when he was 3 years old
in K.V. Delhi School upto 3rd grade following which he was sent to live with his maternal aunt in U.P.
Upon returning he took admission in Hindbal Najafgarh School where he completed his education up
to 10th grade. The patient was often bullied by his classmates and friends. He had limited number of
friends, with most friendships existing at superficial level. Academically, the patient was a below
average student, not actively participating in the extra-curricular activities. After completing his 10th
grade, he changed his school and took admission in Number 3 Government Boy’s School. The patient
reported making friends during this time and continues this friendship till date.

College History: The patient graduated from Delhi University Open Learning however regrets opting
this mode of education as it did not give him opportunities to socialize and make friends. He reported
having no friends during this period and mostly felt lonely.

Occupational History: In 2019, the patient joined E.I Touch and worked there in Labeling for 2.5 years
before moving to Cognizant in 2022 as a Content Moderator for 10 months. His contract at Cognizant
did not renew so he moved to ByteDance in 2021 and continues to work there currently.
 Personal History
Sexual and Marital History: The patient reported gaining sexual knowledge at the age of 14
years through internet. He indulges in masturbation without any feelings of guilt.

Legal History: No legal history reported.

General pattern of living: The patient follows a regime which includes office work and working
out at the gym however, due to poor social network he is lonely during his free time. At this time he
mostly stays in his room where he keeps ruminating about past experiences starting from
childhood until recent episodes. He reports these thoughts are mostly negative and scares him
deeply making him feel highly insecure and lonely to the extent that he sometimes makes death
wishes but has never planned the same. To avoid this loneliness he engages in conversations with
friends and acquaintances without them being present in his room. The patient further reported
his interest in meditation and claims practicing the same on regular basis. He reported enjoying an
opportunity to volunteer for human service for a week in Sadhguru’s ashram in August 2022.

IMPRESSION: The patient faces challenges in establishing and maintaining relationships owing to his anger issues, poor
self-esteem and insecurities manifesting into impairment of social cognition. This culminates into loneliness exacerbating
negative feelings and thoughts resulting in maladaptive behaviour.
 Pre-morbid Personality
Social Relationships: The patient reported feeling lonely thereby expressed a strong desire to form
connections however, he lacks a healthy social network. His poor social skills often creates an
hindrance to establish friendships and if at all he creates bond his anger issues, insecurities and
negative thought process often derails the relationships.

Character: The patient holds overvalued attitude towards himself. He reported that all the conflicts
experienced in relationships are essentially the other person’s fault. He has very low tolerance for
stress which often leads him into anger outburst and impulsive behavior. He reported fulfilling his
responsibilities at work on an average level and at home he mostly forgets tasks assigned to him by his
mother. The patient further reported his colleagues’ impression of him as a good man.

Attitude: The patient identifies himself as a victim in every relationship and friendships he has. He
also reports deficit in focus that takes him to the past where he mostly engages in self-loathing and
diminished sense of self. He reports not giving his best at work and knows he has scope for
improvement. The patient further reports not enjoying his work much and is seeking career
counseling as he feels aimless and worthless gradually developing a negative self view.
 Pre-morbid Personality
Intellectual Activities, Hobbies and Use of Leisure Time: The patient reported that he enjoys working
out at the gym and practices meditation regularly. He reported being lonely mostly during leisure time
thereby engaging in illusory conversations and silly smiling reported to him by others.

Predominant Mood: Dysphoric

Habits/Dependence: N/A

IMPRESSION: Maladjusted personality.

MENTAL STATUS
EXAMINATION
 Appearance
General Appearance and Behaviour: A fair-skinned young male, well kempt and appropriately
dressed entered the OPD unaided. He was in touch with the surroundings. He appeared anxious as he
was eagerly leaning forward while sharing his concerns with the examiner.

Attitude & behaviour towards Examiner and Rapport: Attitude towards the examiner varied from
guarded to being co-operative. He was compliant to the tasks assigned however, was distressed while
performing them. Rapport was established with some difficulty.

Psychomotor Activity: Patient was fidgeting and irritable repeatedly shifting his gaze away for brief
moments during interaction. His demeanor was continuously in an alarming state and he would draw
himself back when queried about topics he possibly resented. He exhibited passive aggression
including sarcastic smile when enquired about his relationship with his deceased father.
 Speech
Speech was non-spontaneous at a normal rate
within appropriate pace and volume for the context.
Tone was expressive. It was coherent, goal-
directed, relevant to the question asked with
normal reaction time.
 HIGHER MENTAL FUNCTIONS
Orientation

Attention and Concentration Q. Can you tell me the approximate

time?
1. Digit Forward: 5/6 A. Around 12:30 pm.

2. Digit Backward: 3/6 Q. Where are you right now?

A. SGT University, 2nd floor, Clinical
3. Serial Subtraction (100-7): - Was Psychology Department.
correct up to 93, 86, 79, 72…………..
Q. Who am I?
A. Therapist.
Impression: Attention was aroused but
could not be sustained. Impression: Patient was alert and well
oriented to time, place and person.
 HIGHER MENTAL FUNCTIONS
Memory Abstract Thinking
1. Similarities:
1. Immediate Memory:
• Chair and Table: Dono wood se bante hain
• Watch and Ruler: Dono measurement ke liye use
2. Recent Memory:
hote hain
• What did you have for breakfast?
Ans: Sandwich
2. Differences:
• Table and Chair: table mein padhte hain aur chair
3. Remote Memory: mein baiththe hain
Name of your school? • Watch and Ruler: Dono alag cheezein mesure
Ans. Hindbal, Delhi karte hain.
• When did you start your first job? 3. Proverbs:
Ans. 2019. • Id ka Chand: Kam milna
• Andho me kaana raja:
Impression: Immediate, Recent and Impression: Thinking was present at functional
Remote Memory were intact. level.
 HIGHER MENTAL FUNCTIONS
Intelligence
A. General Fund of Intelligence:
Q. How many weeks are in a year? - 48 Weeks.
Q. Why do people have lungs? - Breathing.
Q. Where does the sun rise from? - From east.
Q. How many colours are in the Indian Flag? - 3 Orange, white and green.
Q. Name 4 Prime Minister other than Narendra Modi? - Jawaharlal Nehru, Indira Gandhi,
Dr. Rajendra Prasad, Atal Bihari.

B. Simplex and Complex:

Simple and complex arithmetic and word problems were asked from the patients.
• 4+6 = 10, 14+17 = 31, 8-5 =3, 43-38 = 5
• 2*8=16, 21*5=105, 56/8 = X, 128/8=16

Impression: Average intellectual functioning.

 Affect

• Subjective affect: “gussa bahut aata hai.”

• Objective affect: Dysphoric.
• Range : Restricted
• Reactivity : Normal
• Communicability : Normal
• Appropriateness : Inappropriate to the
context.
• Congruence : Incongruent to the mood
 Thought
1. Flow/Stream: No abnormalities detected in flow and stream of thought.

2. Form: No abnormalities detected.

3. Possession: No abnormalities detected.

4. Content: Thought content reflected regarding varied issues from abusive father to built up
anger and resentment “bahut gussa aata hai aur chid machti hai, aisa lagta hai har waqt tokte
rehte hain”.
Persistently worries about loneliness “ weekends mei akela rehta hu, bahut lonely feel karta hu”.
Persistent mistrust of others which are mostly irrational, “ye sab aise kyun hota hai sab mera
fayda utha lete hain”.
Repetitive maladaptive thoughts “baar baar khayal aate hain, wo sab yaad aata hai, mere doston
ne aisa kyun kiya, bachpan ki baatein aur Jo suffering main akele dark room mein feel karta hu
wo khuli aankhon se kisi ke saamne nahi kar pata”.
PERCEPTUAL DISTURBANCES

Hears his father’s commanding

voice ( to explore further)
Silly smiling.
 JUDGEMENT
SOCIAL JUDGEMENT: According to the observations and interviews with the patient he has
attribution errors, difficulty maintaining relationships, over valued ideas towards self, persistent
irrational mistrust of others.

PERSONAL JUDGEMENT:
• Q: Jab aapki tabiyaat theek hojayegi tab kya karoge?
A: Dost banenge aur career pe focus karna hai par samajh nahi aata.

TEST JUDGEMENT:
• Q. What will you do if you see smoke in a room?
A: Aag bujhaane ki koshish karunga
• Q. What will you do if you see a letter with a stamp?
A: Agar address ya number hoga tho call kar dunga

Impression: Impaired Social Judgement. Personal and Test Judgement was

intact.
 Insight
Q: Kya aapko lagta hain ki aap ko koi beemari hai?

R: “pta nahin bas gussa bahut aata hai”

Q. Kya apko lagta hai ki aapke vichaar, mann ya vyavhaar mei koi dikkat hai?

R: “nahin, pta nahin par log mera fayda utha lete hain”

Q. Kya apko lagta hai ki aapke dikkat dimaagi dikkat hai?

R: “Pta nahin”

Q. Aapko kya lagta hai ki dikkat kis wajah se hai?

R. “main convince nahi kar pata aur sab mujhe he galat prove kar dete hain”

Impression: Grade 3 level of insight

Aware of being sick but blaming on others

 Index patient A.S. 26 years old, Hindu, unmarried, male, currently
employed belonging to lower middle socio-economic status, hailing
from sub-urban background came with chief complaints of anger
outburst including self harm since childhood, hearing father’s voices

DIAGNOSTIC and repetitive intrusive thoughts and images from the past, re-
experiencing past memories, feeling diminished and worthless,
attention deficit, interpersonal difficulties and suspiciousness over the

FORMULATION last 3 years. The illness had an insidious onset, continuous course and
a deteriorating progress, with the predisposing factor being choleric
temperament and uncongenial home environment; exposure to series
of prolonged, repetitive childhood physical abuse by father served as
the precipitating factor and poor social network and maladaptive
thoughts were contributory perpetuating factor came to the Clinical
Psychology OPD.
 On MSE, a young male of stated age, mesomorph built, well kempt entered the
OPD room unaided. He was in touch with the surroundings. The patient
appeared anxious and irritated. Rapport was established with some difficulty.
Psychomotor activity included forward leaning posture with eager demeanour
exhibiting restlessness, anxiousness and agitation . The patient was anxious yet
cooperative. Speech was non-spontaneous, relevant, coherent, goal directed
with normal reaction time, normal pitch, tone and volume. Attention was
aroused but could not be sustained as the patient shifted his gaze away staying

DIAGNOSTIC there for brief moments before returning back into the session. He was oriented
to time, place and person with intact immediate, recent and remote memory.
Thinking was found to be at functional level with average intellectual functioning.

FORMULATION Affect was dysphoric, communicable, inappropriate with the context and
incongruent with thought content within limited range and normal reactivity. No
disturbances were elicited in thought stream, form and possession. Thought
content reflected varied issues from abusive father to built up anger and
resentment, interpersonal struggles culminating into loneliness, persistent
mistrust of others which are mostly irrational and repetitive maladaptive
thoughts. Perceptual disturbances included hearing father’s voice commenting
on his everyday actions, and silly smiling at work. Personal and test judgment
were intact however, social judgement was impaired with insight level of grade 3.
 Provisional Diagnosis
6B41 – Complex PTSD.
POINTS IN FAVOR
• Exposure to series of traumatic childhood physical abuse for
years. POINTS AGAINST
• Re-experiencing the traumatic event in the present in the form of
vivid intrusive images or memories; flashbacks in mild form – • Persistent perceptions of heightened threat
transient sense of event occurring again in the present. • Adapting new behaviors to ensure safety
• Re-experiencing the events accompanied with overwhelming
emotions, similar intense emotions of anger and irritability that was
experienced in the past at the time of the event.
• Avoidance behaviour ( external avoidance in conversations)
• Diminished startled reaction
• Pervasive problem in emotional regulation
• Persistent difficulties in sustaining relationships
• Persistent feelings of diminished self – worthlessness
 Differential Diagnosis
6A22 – Schizotypal Disorder

POINTS IN FAVOR
• enduring pattern of eccentricities in behavior, appearance
and thoughts
• cognitive and perceptual distortions POINTS AGAINST
• reduced capacity for— interpersonal relationships
• inappropriate affect • No odd speech
• Paranoid ideas • No anhedonia
• ideas of reference • No unusual beliefs
• Auditory hallucination ( but not of sufficient intensity to
meet the criteria for schizophrenia, schizoaffective or
delusional disorder)
PSYCHOMETRIC
ASSESSMENT
 Rationale For Testing
To confirm the diagnosis: In order to uncover underlying issues that may not be apparent
through clinical interviews and provide evidence to support clinical diagnosis especially if the
diagnosis is unclear. It helps in screening purposes for early detection for certain mental health
conditions if present. It helps reveal cognitive impairments, personality traits or emotional
problems that maybe contributing to patient’s problem

To understand the personality and interpersonal relationships of the patient: To know the
personality structure of the patient which involves the dominant traits and response patterns used
by the patient in stressful circumstances. The patient’s manner of interaction with others and
formation and maintenance of interpersonal relationships are also important facets which will be
revealed by these tests.

For assessment of assets and limitations of the client which will aid in preparing the
management plan.
Tests administered and their Rationale

To assess the attention and concentration span of

Eysenck series of digit span
the patient which was affected by the illness

To assess the structure of personality and understand

Rorschach Psychodiagnostics the patient’s psychopathology. It also helps in having
a diagnostic clarification

To understand the patient’s interpersonal relationship

Thematic Apperception Test and manner of interaction and involving
communication and responding to other individual.

To understand the underlying clinical patterns of

Millon Clinical Multiaxial Inventory- III (MCMI-III) personality and to assess the psychopathology for
confirmation of diagnosis
 Tests administered and their Rationale
To assess the severity level of symptoms associated with
Hamilton Anxiety Rating Scale (HAM-A)
anxiety.

To assess the severity level of symptoms associated with

Hamilton Depression Rating Scale (HAM-D)
depression.
 Behavioural Observations
The patient had a positive attitude towards the
examiner and the assessment procedure. He was
cooperative but distressed during the assessment.
The patient faced difficulties specially during
Rorschach and TAT tests as he struggled to focus
and gather thoughts to respond. He was unable to
give adequate responses even though he
understood the importance of psychometric tests
for his treatment.
 TEST
FINDINGS
 TEST FINDINGS
Eysenck Digit Span Test

Digit Forward: 5/6

Digit Backward: 3/6

The patient’s attention could be aroused but was

sustained with difficulty.
 Millon Clinical Multiaxial Inventory
SCALE RAW SCORE BR SCORE SCALE RAW SCORE BR SCORE

X DISCLOSURE 156 S SCHIZOTYPAL 13 66

Y DESIRABILITY 12 55 C BORDERLINE 20 85

Z DEBASEMENT 23 81 P PARANOID 21 88

1 SCHIZOID 4 35 A ANXIETY 15 93

2A AVOIDANT 11 66 H SOMATOFORM 4 53

2B DEPRESSIVE 15 68 N BIPOLAR-MANIC 11 73

3 DEPENDENT 16 78 D DYSTHYMIA 6 84

4 HISTRIONIC 19 56 B ALCOHOL DEPENDENCE 6 64

5 NARCISSISTIC 10 35 T DRUG DEPENDENCE 5 60

POST TRAUMATIC
6A ANTISOCIAL 13 66 R 19 88
STRESS
6B SADISTIC 19 70 SS THOUGHT DISORDER 16 68

7 COMPULSIVE 16 44 CC MAJOR DEPRESSION 11 80

8A NEGATIVISTIC 26 94 PP DELUSIONAL DISORDER 6 63

8B MASOCHISTIC 11 69
Millon Clinical Multiaxial Inventory
(MCMI-III) SIGNIFICANT FINDINGS
SCALE RAW SCORE BR SCORE

NEGATIVISTIC 26 94

ANXIETY 15 93

PTSD 19 88

PARANOID 21 88

BORDERLINE 20 85

DYSTHYMIA 6 84
THEMATIC APPERCEPTION TEST
Plot of the story - Bizarre and Unstructured
Organization of Story – Poor
Length of story – Emotional Blocking and inhibition
Content – Sexual, Abstract, Borrowed, Aggressive, Depressed, Suicidal, Picture Rejection
Range of Imagination - Childlike

HERO Varied (mostly others and sometimes Self)

NEEDS Affiliation, Play and Achievement

PRESSES Physical danger and Uncongenial Environment.

EGO & Loose and disintegrated/Mostly maladaptive and

SUPEREGO/ Coping Mechanism sometimes adaptive
 Rorschach Inkblot Test (RIBT)
Structural Summary
R = 24 L =0.8 FC:CF+C = 1:4 COP = 0 AG = 0
Pure C = 2 GHR:PHR = 4:5
EB = 0:4 EA = 4 EBPer = 4 SumC':WSumC = 4:4 a:p = 2:2
eb = 3:8 es = 11 D = -2 Afr = 0.55 Fppd = 1
Adj es + 11 Adj D = -2 S=0 SumT = 3
Blends:R = 1:27 Human Cont = 6
FM = 3 SumC' = 4 Sum T = 3 CF = 0 Pure H = 0
m=1 Sum V = 1 Sum Y = 0 PER = 3
Isol Indx = 0.11

a:p = 2:2 Sum6 = 4 XA% = 0.86 ZF = 12 3r+(2))/R = 0.37

Ma:Mp = 0:0 Lv2 = 0 WDA% = 0.91 W:D:D6= 5:18:5 Fr+rF = 0
2AB+Art+Ay = 4 WSum6 + 19 X-% = 0.14 W:M = 5:0 SumV = 1
Mor = 1 M- = 0 S- = 0 Zd = 6 FD = 0
Mnone = 0 P=2 PSV + 0 An + Xy = 1
X+% = 0.29 DQ+ = 3 MOR = 1
Xu% = 0.59 DQv = 5 H:(H)+Hd+(Hd) = 0:6

PTI = 1 DEPI = 5 CDI = 4 S-CON = 6 HVI = 2 OBS = 2

 Cognitive Functions

The patient’s attention could be aroused but could not be sustained (Digit forward = 5) (Digit
Backward = 4). The patient’s cognitive and visual functions were intact and no organic brain
abnormality was seen. Severe distortions appeared in the minus answers, suggesting a serious
breakdown in the cognitive operations related to mediation that is not unlike that found when
psychotic-like activities are present (FQx- = 4). The presence of multiple minus answers that have
severe distortion suggests that the patient’s mediational activity maybe chaotically disrupted in
ways that will inevitably breed ineffective and/or inappropriate behaviours in the patient (FQx- = 4).
The findings suggests that (P=2) the patient has a persistent tendency to disregard social
conventions or expectations in favour of individual needs or wants.
Further findings indicate a more lackadaisical, defensive, or even impaired mediational approach in
the patient. (FQ+=0).
 Cognitive Functions
The patient is not very influenced by social demands or expectations. This is not necessarily a
liability; however, it is very likely that many behaviours may be formulated by the patient that
disregard or avoid issues of social convention (Xu%=0.59; X-%=0.14).
The patient is inclined to merge feelings with thinking during problem solving or decision making
and being an extratensive the patient relies much more on feelings thereby the impact of emotions
on ideation often give rise to more complex patterns of thought.
The patient tends to be more accepting of logic systems that are precise or marked by greater
ambiguity (EB=0:4 (L=0.8). The patient may count on external feedback for reassurance, and their
judgments are often based on the results of trial-and-error behavior.
Conversely, (EBPer = 4) further findings suggests that the patient’s style is quite pervasive and
emotions will almost always have a considerable influence on patterns of thinking, even in
situations when this more intuitive approach may be less effective.
 PERSONALITY
The patient has an elevated score on Scales: Negativistic = 94, Anxiety = 93, PTSD = 88, Paranoid = 88, Borderline = 85
and Dysthymia = 84. The MCMI findings are suggestive of emotional suppression, social deviance, hyperarousal,
avoidance and hypervigilance. The patient is often impulsive, dysphoric, aimless, hopeless, negativistic on trivial matters,
ruminating over intrusive thoughts, often feels others are taking advantage of him. His severe distress is the result of his
inability to maintain his relationships and frequent anger outburst across various social settings.
The patient experiences tension, moodiness and loneliness while he desires to be in relationship however he in unable
to maintain them.
The personality organization of the patient includes a potential for frequent experiences of affective disruption.
Findings suggests that the patient often complain about recurring bouts of depression, moodiness, tension, or anxiety
(DEPI=5; CDI=4). The patient is extratensive (EB=0:4) also indicating being overwhelmed or flooded by emotion These
findings suggests that the patient is undergoing very strong emotions which are interfering markedly with his thinking
and are especially impairing to the abilities necessary for attention and concentration during decision-making. The
intensity of these emotions is quite disruptive and, typically, ideational and/or behavioural impulsiveness occurs
(EB=0:4).
 PERSONALITY
The patient is in some distress as in depression or anxiety, or it can be more indirect as in unusual tension,
apprehension EB=3:8). Findings suggests that the patient is highly vulnerable to loss of control and becoming
disorganized under stress further suggesting that the patient is chronically vulnerable to ideational and/or affective
overload (AdjD = -2).
The findings indicate (SumC’=4) that there is an excessive internalization of feelings that the patient would prefer to
externalize. (D= -2) it is reasonable to assume that the patient is highly susceptible to difficulties in control.
(OBS=2) signifies the presence of a mental set regarding correctness or perfectionism in the patient.

HVI signifies the presence of trait-like feature having a significant impact on his conceptual thinking. This finding
indicates the patient uses considerable energy to maintain a continuous state of preparedness.
HVI=2) (MOR=1) the finding suggests the patient has negative impressions about self.
Further findings indicate the patient maybe less mature, and frequently have very distorted notions of himself. This
more limited self-awareness sometimes serves very negatively in decision-making and problem-solving activity and
creates a potential for difficulties for the patient in relating to others. (H = 0; R=27)
 INTERPERSONAL
RELATIONSHIP
The patient has difficulty in interpersonal relationships. The patient is less socially mature than might be expected. The patient
has limited social skills and is likely to face frequent difficulties while interacting with the environment, especially the
interpersonal sphere. He seeks out close and enduring relationships, but his ineptness frequently makes him less
acceptable to others, or even vulnerable to rejection.
The findings also indicates that the patient easily becomes dissatisfied with his life and often experience a sense of
confusion or helplessness about his social situation. In fact, he may experience periodic bouts of depression as
reactions to his social failures (CDI=4) .
Further findings also indicate (Fd=1) that the patient may be expected to manifest many more dependency
behaviours than usually is expected. The patient may often incline to rely on others for direction and support, and
tends to be rather naive in his expectations concerning interpersonal relations.
,
 INTERPERSONAL
RELATIONSHIP
The findings indicate the patient may want close emotional relations with others, but is often at a loss about how best to achieve them.
Sometimes, the intensity of their needs clouds their logic (T=3). The patient's interpersonal behaviours will be less effective in many
situations and often will be regarded unfavourably by others (GHR: PHR=4:5). Further findings also suggest the patient may be more
defensive in interpersonal situations than most people relying on displays of information, he feels less secure in such situations involving
challenges (PER=3).
Patient’s needs revolve around the need of Affiliation, Play and Achievement
He may experience the environment to be uncongenial environment.
He uses the defense mechanism of Avoidance, Acting out, Dissociation
 HAM-D and HAM-A

• Hamilton-Depression Rating Scale (HAM-D)

The patient obtained a score of 12, which
indicates Mild Depression.

• Hamilton- Anxiety Rating Scale (HAM-A)

The patient obtained a score of 11 which
indicates Mild anxiety symptoms.
 Diagnostic Indicators
• HAM-A = 10; indicating Mild anxiety
• HAM-D = 11; indicating Mild depression
• MCMI: Elevated score on Scale Negativistic = 94, Scale Anxiety = 93, Scale PTSD = 88, Scale
Paranoid = 88, Scale Borderline = 85, Scale Dysthymia = 84
• RIBT: DEPI = 5, CDI = 4, PTI = 1, S-CON = 6, HVS = 2

TAT: Needs (Achievement, Affiliation and Play), Press (Physical injury and Uncongenial Environment).
Plot of the story - Bizarre and Unstructured
Organization of Story – Poor
Length of story – Emotional Blocking and inhibition
Content – Sexual, Abstract, Borrowed, Aggressive, Depressed, Suicidal, Picture Rejection
Range of Imagination - Childlike
 SUMMARY
The index patient experiences attention and concentration deficits. Patient has
increased aggressiveness, impulsiveness including self-harm, anxiety, low mood,
hopelessness and irritability. Childhood trauma endured by the patient has significantly
contributed in the development of his negativistic and paranoid temperament
accompanied with maladaptive coping mechanisms. The patient easily becomes
dissatisfied with his life and often experience a sense of confusion or helplessness
about his social situation. In fact, he experiences periodic bouts of depression as
reactions to his social failures . The patient’s low tolerance for stress manifests into
anger outburst disrupting interpersonal relationships which the patient attributes to
external origins. In order to cope with his loneliness the patient engages in self-
muttering (rehearsing/making conversations) with his friends and acquaintances.
 IMPRESSION
Test findings indicate that the patient experiences recurrent distressing memories of the
traumatic events which includes avoiding conversations of the distressing memories. The
patient experiences persistent negative emotions like anger, guilt, shame. He expresses
persistent and exaggerated negative beliefs about self and others. He exhibits marked
arousal and reactivity including irritable behavior, anger outbursts, anxiety, self-
destructive behavior, problems falling asleep and concentration difficulties.
Findings further indicates the patient uses considerable energy to maintain a continuous
state of preparedness. This anticipatory or hyperalert state is related to a negative or
mistrusting attitude toward the environment that evolved during the developmental years
of the patient. It is apparently formed by an accumulation of events in which the patient
as a child found it impossible to accurately predict the response of significant others to his
behaviors, especially emotional behaviors which led to a sense of vulnerability and
insecurity when forming or implementing behaviours in the patient.
The findings are suggestive of emotional suppression, social deviance, hyperarousal,
avoidance and hypervigilance making him socially inept in forming and maintaining
relationships.
 PROGNOSTIC FACTORS

GOOD FACTORS: POOR FACTORS

• Regularity in therapy
No family support
session.
• Motivation to get better
Poor social network
CASE
CONCEPTUALISATION
The Memory and Identity Theory of ICD-11 Complex Posttraumatic Stress Disorder Note. ICD-11 = International
Classification of Diseases; PTSD = posttraumatic stress disorder; DSO = disturbances in self-organization. See the
online article for the color version of this figure.
 Difficulty in
maintaining
relationships Avoidance of
conversations of trauma

Physical
abuse by
father Flashbacks
since Avoidance
childhood Shame, Guilt, Worthless Hyperarousal
Diminshed, Defeated DSO – Affect
dysregulation, negative
self-concept &
relationship problems

Suicidal thoughts
Family is not aware of Loneliness
treatment Aimlessness
Friends don’t understand me

Key factor sets from the IMPAIRED SOCIAL BONDS MODEL (Charuvastra & Cloitre; 2008) and the
AFFECT DYSREGULATION MODEL (Ford, 2015) were incorporated into the CASCADE MODEL
 EYE MOVEMENT DESENSITIZATION
AND REPROCESSING (EMDR) THERAPY
A structured therapy that encourages the patient to briefly focus on
the trauma memory while simultaneously experiencing bilateral
stimulation (typically eye movements), which is associated with a
reduction in the vividness and emotion associated with the trauma
memories.
 MANAGEMENT
SHORT TERM GOALS LONG TERM GOALS
• Develop coping strategies: Teach the patient immediate • Process traumatic experiences: Utilize EMDR (Eye Movement
techniques to manage anger and self-harm impulses when they Desensitization and Reprocessing) therapy to process and
arise, such as deep breathing exercises or grounding integrate traumatic memories, reducing their emotional charge
techniques. and their influence on present behavior.

• Increase self-awareness: Help the patient recognize the triggers • Improve emotion regulation: Help the patient develop more
and early signs of aggression and self-harm, enabling them to adaptive ways to regulate emotions, such as mindfulness
intervene before these behaviors escalate. practices and emotional awareness exercises.

• Psychoeducation: Provide education about Complex PTSD, • Enhance interpersonal relationships: Work on improving
including its symptoms and how past traumatic experiences may communication skills and interpersonal boundaries to foster
be influencing current behaviors. healthier relationships and reduce conflicts that may contribute
to aggression.
• Establish safety: Collaborate on a safety plan to minimize the
risk of harm during periods of distress, including identifying • Increase self-esteem and self-compassion: Support the patient in
support networks and crisis interventions. building a more positive self-image and self-worth,
counteracting the negative beliefs often associated with
• Reduce frequency and intensity of outbursts: Work towards Complex PTSD
decreasing the frequency and intensity of aggressive outbursts
and self-harming behaviors through structured anger • Relapse prevention: Develop strategies to maintain progress and
management techniques prevent relapse, including ongoing therapy, social support, and
self-care practices to manage stress and triggers effectively.
 THERAPY PROCESS PLAN
INITIAL PHASE MIDDLE PHASE TERMINATION PHASE

• Taking detailed case history • Psychoeducation – C-PTSD • Review patients progress and areas of
• Ventilation • Identifying Anger Triggers, response and improvement.
• Psychoeducation - Anger emotions • Reinforcement of management
• Psycho-diagnostic Assessment • Identifying problem behaviour strategies
• Sharing test findings • Identifying affect dysregulation • Discussing probable future stressors and
• Anger Management Journal • Identifying specific traumatic memories implementation of management
• Grounding Techniques • Reprocessing of traumatic memories strategies
• Installation of positive beliefs ( context with
trauma)
 INITIAL PHASE
SESSION 1 & 2 :
To explore the chief complaints, history of illness and
to familiarize the patient into the therapy process.
Session conducted:
• Considering the history of the illness and intensity of
his concerns, patient was allowed to ventilate. His
emotions were validated and experience of such
emotions was acknowledged.
• Brief MSE was taken.
• Clinician rating scale (HAM-D, HAM-A) were
administered
Patient was psycho-educated regarding the
therapy process and need for medication.
 INITIAL PHASE
SESSION 3 & 4:

• Psychometric Assessments : To understand the

psychopathology of the patient.
• Psychoeducation regarding his symptoms were
done.
• Patient was psychoeducated about anger, its
causes and manifestations and the need for
anger management intervention for
improvement of symptoms was emphasized.
• Accordingly, anger management intervention
was initiated.
• Grounding techniques were administered
ANGER MANAGEMENT JOURNAL
 INITIAL PHASE
SESSION 4 & 5 :

• Continued with Psychometric Assessments.

• Anger management techniques were explained to the patient and
role-play was conducted during sessions.
• Patient was psychoeducated about impulsive behavior by
elaborating on the interplay between emotional and logical brain
on our response/reaction. Accordingly, anger diary was explained
so he could track his triggers, response and emotions after the
outbursts in order to create awareness.
• Importance of ”letting go” was explained with the help of
“Holding Glass” activity so he could accept the break-up and
move on.
 MIDDLE PHASE PLAN
SESSION 6-12

Activating the processing of the trauma memory – To naturally move it toward the adaptive information it needs
for resolution.
Assessment of Patient’s Readiness –
Eye Movement Rehearsals
Preparation phase
Assessing the Target Memory
Validity of Cognition and Subjective Units of Disturbance scales
Desensitization
Processing the memory to Adaptive Resolution
Installation
Body Scan
Closure
Re-evaluation
 TERMINATION PHASE
• Objective : To take Review of the patients progress and areas
of improvement.
• Management strategies employed by the patient will be
reinforced
• Probable future stressors and associated risks of relapse will be
discussed and implementation of management strategies in such
situations will be emphasized.
• Monthly follow up will be recommended in order maintain the
progress.
Many abused children cling to the hope that growing up will bring escape and
freedom.

But the personality formed in the environment of coercive control is not well adapted
to adult life. The survivor is left with fundamental problems in basic trust, autonomy,
and initiative. She approaches the task of early adulthood――establishing
independence and intimacy――burdened by major impairments in self-care, in
cognition and in memory, in identity, and in the capacity to form stable relationships.”

She is still a prisoner of her childhood; attempting to create a new life, she
reencounters the trauma.

Judith Herman (Trauma and Memory)