CASE PRESENTATION

DR. AAKRITI SOOD

 PERSONAL INFORMATION
• Name: Mr. x
• Age: 44 years
• Gender: male
• Educational qualification: B.Sc in Biology
• Occupation: clerk , currently not working since 1 month
• Religion: Hindu
• Marital status: Married x 20 years
• Resident of U.P , living in a joint family.
• Socioeconomic status: upper middle SES
INFORMANTS
Informants
SELF
Wife : 42 year old female, graduate working as a hindi teacher in a
government school. Stays with the patient in the same house.

The information provided is clear, coherent and in chronological order.

Therefore, information provided is reliable, adequate and complete.
 CHIEF COMPLAINTS
• Self : “ agar koi cheez touch hojae toh baar baar touch karne ka man
karta hai ”
“ baar baar vichar aate hai “
• According to wife : “ baar baar hath dhota hai ”
“ both sochta hai ” x 12 years
COURSE SPECIFIERS
• Onset: insidious
• Course: Continuous and fluctuating
• Duration: 12 Years
• Precipitating factors: Death in the family
• Perpetuating factors: poor compliance
 HISTORY OF PRESENT ILLNESS
Patient was apparently well 12 years ago when there was a death in the family
and patient had to carry out all the rituals. He was supposed to touch the feet of
his aunt before lighting the pyre, but he did the same after pyre had burnt
completely which was against the rituals of the family.
Immediately after he felt guilty and asked for forgiveness. He kept asking for
forgiveness till they reached home. After reaching his house, he took bath and
sat in front of the god and asked for forgiveness. This continued over the next
few days,whenever he saw a religious place he had the urge to ask for
forgiveness multiple times and if he tried to resist his urge he would feel
uncomfortable till the time he would complete the task.
 HISTORY OF PRESENT ILLNESS
• His family members also started noticing that he would bow his head
multiple times whenever he saw a religious place. He would bow his
head twice and then four times and so on and would keep repeating the
same till he would feel satisfied.
• Over the next few days he started asking his wife to wash his clothes
separately. If he ever saw her washing his clothes with other family
member’s clothes he would get distressed and anxious and would ask
her to wash them again. He wanted her to wash them in a specific
manner. On being confronted about the same he could not state the
exact reason for his behaviour.
 HISTORY OF PRESENT ILLNESS
• His family members noticed that he started spending more time while
washing hands and would wash his hands every time he touched any
object by mistake. He would take 10-15 minutes to wash hands.
Initially he tried to resist but could not as he would get distressed and
would keep thinking about it. He would wash his hands in a specific
manner. He would first wash his fingers , then he would wash till his
wrists and then till his elbows. He would do this once but would be
uncomfortable and would repeat it till the time he was satisfied.
• Eventually he started keeping a count. He would wash his hands once
but would still be unsatisfied and would repeat this twice, four times,
six times and in similar fashion sometimes till 64 times. He would use
one soap per day.
 HISTORY OF PRESENT ILLNESS
• Following this behavior , his family took him to psychiatrist in Aligarh
and took medications for 6 months (Details not available). According
to the patient tablet Fluvoxamine 50mg BD was prescribed and he
reported 90% achievement. He would still bow his head multiple times
whenever he saw a religious place but other than this , there was
improvement in all other symptoms. Without following up with the
doctor, he stopped the treatment.
• After a few months, patient had previous complaints again. He even
started washing his clothes on his own. He would wash his clothes in a
specific manner. He would wash each and every cloth separately and
would put them to dry separately. He would then take bath. He would
first wash all the taps and would then bathe.
 HISTORY OF PRESENT ILLNESS
• He takes 30 – 40 mins to bathe. He has to follow a specific routine
every time he takes a bath. If he doesn’t follow that , he has bechaini
and ghabrahat. After bathing , he would not allow anybody to touch
him. He would not sit on bed without changing into his night clothes.
• Over the next few weeks he started counting every activity that he
performed e.g.- he would count the number of times he wash his hands
or if he touched any object , he would keep a count, if he would bow
his head, he would count the same. If he missed the count or forgot in
between he would start again, if he did not do it would feel distressed
and would feel like he could not cope up . He then took treatment from
the same doctor and continued the treatment for 4 years.
 HISTORY OF PRESENT ILLNESS
• There was some improvement except that he still washed his clothes
by himself and he fail to do so he would feel distressed and would
keep thinking about it.
• Gradually the symptoms started worsening.
• He would get repetitive images about different gods, something he
would get naked images of god and this would cause discomfort and
he would feel guilty for which he would ask for forgiveness multiple
times while keeping a count of 2,4,6,8 and so on
• If he failed to do so he would start again.
 HISTORY OF PRESENT ILLNESS
• He took on and off treatment from various doctors but his symptoms
worsened over time
• His work also started getting affected as he would do the same even at his
workplace. He was so distressed that he was not able to control these
thoughts and images that he stopped going to his workplace.
• He would sleep the whole day and whenever he was awake his time would
be consumed either in washing hands or praying in front of god whenever
he pass by religious place. His appetite also reduced. Earlier he used to eat 5
chapatis per meal , now he would hardly eat 2-3 chapatis per day . His
family members were not able to help him anymore and then they decide to
bring him to SGT Hospital for further evaluation.
 NEGATIVE HISTORY
• No h/s/o aggressive obsessions, hoarding obsessions, obsessions with need
for symmetry, pathologic doubt/checking compulsions, hoarding
compulsions.
• No h/s/o hair pulling, skin excoriation, hoarding or any body dysmorphia.
• No h/s/o free floating anxiety.
• No h/s/o persistent and pervasive change of mood.
• No h/s/o muttering to self, hearing voices, seeing images not perceived by
others.
• No h/s/o over cheerfulness, decreased need for sleep, big talks.
• No h/s/o consumption of any other substance.
• No h/s/o head injury, loss of consciousness, jerky body movements.
PAST HISTORY
• No history of similar psychiatric complaints in past.
• No h/s/o any other psychiatric complaints.
 TREATMENT HISTORY
• Patient took treatment from various hospitals but had poor compliance.

His latest prescription:

• TAB. FLUVOXAMINE 100 MG BD
• TAB. FLUOXETINE 20 MG OD
• TAB. CLONAZEPAM 0.5 MG BD
 FAMILY HISTORY
• Patients belongs to a joint family. There are 6 members in the family.
• Lives in a self owned house.
• Patient has 2 brothers and 1 sister.
• Patient has an elder son and a younger daughter.
• H/s/o similar complaints in the daughter with repetitive, intrusive thoughts
of dirt and contamination and urge to wash hands and clean the
surroundings since 2 years , currently taking treatment under psychiatry
OPD at SGT hospital.
• No h/o substance use in the family and history of suicide in the family.
• Patient’s family perceive patients symptoms as a mental illness and want
him to seek treatment from a hospital.
FAMILY TREE
 PERSONAL HISTORY
• Birth and developmental : Full term normal vaginal delivery at home.
Cried immediately after birth. No history suggestive of developmental
delay.
• School : B.sc in biology
• Sexual history : Heterosexual . Attained puberty at 12 years of age.
• Occupation : clerk , currently not working since 1 month.
• Marital history : Married since 20 years. Has 1 son and 1 daughter. Has
a cordial relationship with his wife and his kids.
 PREMORBID PERSONALITY
• Social relations : Patient had a cordial relationship with his family members and friends.
• Intellectual activities, hobbies and use of leisure time : patient liked to read about
medicines, listens to old hindi songs and watches old hindi movies in his leisure time.
• Predominant mood : cheerful
• Character:
Interpersonal relations : patient had a cordial relations with his wife and family. Patient was
social and had friends. Took part in social functions and attended gatherings.
Attitude towards work and responsibilities: Helped with chores and responsibilities around
the house.
Religious belief : religious but occasionally performed rituals.
• Fantasy life:
• Habits : denies any use of substance. Used to sleep for 6-8 hours/day.
 GENERAL PHYSICAL EXAMINATION
Patient is conscious, cooperative, well built.

• Weight— 60 kgs Height— 158cms BMI – 24 kg/m2

• Vitals:
Pulse Rate- 84 bpm
Blood Pressure- 126/80 mmHg
Respiratory Rate- 16 per min, regular in rhythm
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal oedema
 SYSTEMIC EXAMINATION
• Cardio-vascular system:
S1, S2 heard, no murmurs or other adventitious sounds heard.

• Respiratory system:
B/l symmetrical; respiratory rate- 16 per minute B/l movement of chest.

• Per abdomen examination:

no local rise of temperature or tenderness, no organomegaly
bowel sounds heard.
 SYSTEMIC EXAMINATION
• Central nervous system:
Patient is conscious, oriented.
Normal gait and posture
Cranial nerve examination normal.
Muscle tone : normal
Muscle power 5/5
Superficial reflexes : Abdomen ++ , Planter : flexor
Deep tendon reflexes : ++
No sensory deficit elicited
No signs of cerebellar dysfunction
 MENTAL STATUS EXAMINATION
• A thin built man walked into the interview room sat on the chair, got
up counted till 2 and sat again, and repeated this twice. Greeted the
examiner. He was constantly fidgeting. He was well kempt
appropriately dressed. Overall personal hygiene was adequate.
• Eye to eye contact: established and maintained.
• Rapport: established

• PMA: increased , constantly fidgeting.

MENTAL STATUS EXAMINATION
Speech
Pitch/Tone : normal
Volume: increased
Reaction time : normal
Clear, coherent, relevant and goal directed.
Mood and Affect – (S) theek hai (O) Anxious
Range : full Reactivity : present
Lability : absent
 MENTAL STATUS EXAMINATION
• Thought – Form – no formal thought disorder
Stream - normal
Possession:
Obsessive thoughts of dirt and naked images of god.
Compulsion to wash hands and take bath in a ritualized manner and ask for
forgiveness and counting compulsion.

“Bhagwan ke baare mei baar baar galat tasveere banti hai dimag mei. Aur fir
baar baar mai maafi mangta hu. Maafi bhi gin kar mangta hu. Agar lagata
hai ginti bhool gya hua toh dubara ginti shuru karta hu . Aur agar esa na
karu toh bechaini hoti rehti hai. ”
MENTAL STATUS EXAMINATION
“baar baar hath dhota hu, 10-15 min lagte hai haath dhone mei , pehle
fingers wash karta hu, fir wrist aur fir elbow tak wash karta hu . Aur fir
gin kar do baar pani dalta hu. Nhate same bhi 30-40 min lag jate hai ,
both koshish karta hu jaldi karne ki par agar ek he tareeke se na nha pau
toh behaini bani rehti hai.”
“ agar koi bhi cheez touch ho jae galti se , usko baar baar touch karne ka
man karta hai aur fir kabhi do 2 kabhi 4 baar or kabhi 64 times bhi touch
karta rehta hu jab tak man ko shanti na mil jae”.
•Perception: no perceptual abnormality present.
 HIGHER MENTAL FUNCTIONS
• Orientation : Patient oriented to T/P/P
• Attention and concentration :
Serial substraction test: able to do 100-7 upto 5 times in 40 seconds.
Immediate : Digit forward – upto 5 digits
digit backwards up to 4 digits
Impression : Attention arousable and sustained.
 HIGHER MENTAL FUNCTIONS
• Memory :
Immediate : 3 object test
Recent : what did the patient have for breakfast ?
Remote : married since 20 years.

Impression : intact
 HIGHER MENTAL FUNCTIONS
• Intelligence :
General knowledge :
Name of the prime minister : correct
5 states of india : correct
Name the months in one year: correct

Abstraction :
Similarities and differences: was able to tell similatries and differences
between chair and table.
Proverbs :
Pet mei choohe khudna : bhookh lagna
 HIGHER MENTAL FUNCTIONS
• Judgement :
Social : intact
Personal : intact
Test :
Letter situation : post office mei bhijwa dunga
Fire situation : pani daal dunga

• Insight : present, grade 6

DIAGNOSTIC FORMULATION
A 44-year-old male ,married , hindu, graduate clerk from upper middle socio-
economic status living in U.P. Patient’s daughter is a diagnosed case of OCD.
(currently seeking treatment from SGT Hospital). He presented with 12 years
of duration of illness which was insidious in onset, had a continuous and
fluctuating course characterized by obsessive thoughts of dirt and images of
god with compulsion to wash hands and take bath in a ritualized manner and
ask for forgiveness for the same with counting compulsions , seeking on and
off treatment with poor compliance along with socio occupational
dysfunction and decreased appetite since 1 month. On MSE findings
psychomotor activity was increased, with increased volume of speech, with
anxious affect and with presence of repetitive, intrusive thoughts of dirt ,
naked images of god and urge to take bath and wash hands in a ritualized
manner with counting and touching compulsions with grade 6 insight.
Differential diagnosis
Obsessive compulsive disorder
Organic
 Management
• Following investigations were sent :
Complete blood count
Liver function test
Kidney function test
Blood sugar profile
Thyroid function test
ECG

Rating scale: Y-BOCS : 32

 Clinical course
• Tab. Fluvoxamine 300mg
• Tab. Clonazepam 0.5mg TDS

ERP to be initiated.