CASE HISTORY 5

Socio-demographic data:
• Name – Shalini
• Age – 43 years
• Sex- Female
• D.O.B – 15 April 1979
• Marital status - Single
• Educational Qualification – BA
• Residential Address - Ghaziabad
• Native Place/Place of Birth - Ghaziabad
• Income – 45000/- per month plus incentives
• Current circumstances of living – Lives alone
• Religion - Hindu
• Socio-Economic Status – Middle Class (Kappaswami Scale)

Informants: Patient herself

Information is adequate and reliable
Reliability of informants: Reliable

Onset: Insidious – slow and gradual

Course: Continous
Duration : Three years

PPM factors:

Predisposing factors: She has always had stage fright and even the thought of speaking in public makes her tremor
worse. When asked to speak in public she develops palpitations, sweating, dizziness and a feeling of butterflies in her
stomach

Precipitating factors: She is due to deliver a presentation next week to the national team, upon which hinges her hope
of a promotion. She says that the thought of doing this presentation is making her feel very panicky.

Perpetuating factors: She feels that she will make a fool of herself in public and therefore goes to great lengths to
avoid such situations.

Effects of symptoms:
1. Self: symptoms of depression, emotional instability, irritability and impulsive behavior.
2. Other mental function: fear, panic, anxiety, insecurity
3. Legal: None
4. Sleep: poor
5. Appetite: decreased over the past 6 months
6. Bowel/Bladder Functioning: Often has loose motions
7. Libido Functioning: NA

Chief Complains: She says that the thought of doing this presentation is making her feel very panicky. She has
always had stage fright and even the thought of speaking in public makes her tremor worse. When asked to speak in
public she develops palpitations, sweating, dizziness and a feeling of butterflies in her stomach. She feels that she will
make a fool of herself in public and therefore goes to great lengths to avoid such situations. She is single and is also
nervous about dating and meeting senior doctors. She feels that her problems have worsened over the past 3 years
since she was promoted to hospital representative. Since then she has tended to fret about forthcoming presentations
and her sleep has been quite poor. Over the last week she has been extremely agitated and has found it hard to
concentrate on anything, so much so that she nearly had a serious road traffic accident. Fortunately, she escaped with
a dent in her car. She reiterates her request for a sick note, as it would be ‘impossible’ for her to do the presentation.
She would like to visit her sister instead.
HOPI (history of present illness) : Patient is due to deliver a presentation next week to the national team, upon which
hinges her hope of a promotion. When she has had to make presentations in the past to her local team, she has used a
‘couple of drinks’ to calm herself. She does not have any formal thought disorder or indeed any other psychotic
symptoms. Since then she has tended to fret about forthcoming presentations and her sleep has been quite poor. Over
the last week she has been extremely agitated and has found it hard to concentrate on anything

Negative History:
Physical examination is unremarkable apart from tachycardia of 100/min. Anxiety of presentations and public
speaking, drinking. Escaping the situation.

Past History: When asked to speak in public she develops palpitations, sweating, dizziness and a feeling of butterflies
in her stomach. When she has had to make presentations in the past to her local team, she has used a ‘couple of drinks’
to calm herself.

Family History: Father used to have anxiety attacks and was depressed

GENOGRAM

Educational /Occupation History: Medical representative, good at her work, due for a promotion.

Sexual and Marital History: She is single and is also nervous about dating and meeting senior doctors. She feels that
her problems have worsened over the past 3 years since she was promoted to hospital representative.

Religious History: Hindu

Pre-morbid Personality: She has always had stage fright and even the thought of speaking in public makes her tremor
worse

MENTAL STATUS EXAMINATION

General appearance and examination

• General appearance and grooming: Smartly dressed, wearing appropriate makeup
• Estimate of age: Age appropriate
• Body Built: Slim and fit
• Touch with surroundings: irritable and uncomfortable
• Eye contact: Establishes and maintains eye contact as necessary
• Posture: appears very fidgety and restless

Psycho-motor activity: She is sweating profusely and keeps fanning herself with a magazine.

Speech: voice becomes tremulous

Mood/Affect: anxious and agitated

Thought/Perception
• Stream: disoriented
• Form: clear and is in context to the questions asked
• Possession: recognizes that her thoughts are her own
• Content: patient speaks spontaneously and with nervousness when questions are asked
• Language: speech is spontaneous, with normal reaction time and pitch
• Perceptual disturbance: She is sweating profusely and keeps fanning herself with a magazine.
• Dreams: none reported as such

Higher cognitive functioning

• Attention – impaired
• Orientation – orientated in time, place and person
• Concentration – impaired, unable to concentrate
• Memory – Intact
• Intelligence – able to answer general knowledge questions
• Abstract ability/thinking – does not have formal thought disorder or any other psychotic symptoms
• Judgment - Intact
• Insight - Grade 6, She acknowledges that she has not sought help ‘all these years’ but expresses her willingness to
try any treatment that is likely to work.

Psychological Testing
• Liebowitz Social Anxiety Scale (LSAS)
• Hamilton Anxiety Rating Scale (HAM-A)
• Beck Anxiety Inventory (BAI)
• Penn State Worry Questionnaire

Diagnostic Formulation:

Patient is 43 years old single female medical representative who lives alone. She is sweating profusely and keeps
fanning herself with a magazine. Periodically, she gets tearful and her voice becomes tremulous. Her mood is clearly
anxious and agitated. In this case the predisposing factor - She has always had stage fright and even the thought of
speaking in public. The Precipitating factors - She is due to deliver a presentation next week to the national team, upon
which hinges her hope of a promotion. The Perpetuating factors -She feels that she will make a fool of herself in public
and therefore goes to great lengths to avoid such situations.

Diagnosis: Based on comprehensive Case- History, Mental Status Examination, and psychological test the diagnosis is
social anxiety disorder 300.23 (F40.10) with panic episodes

Intervention/Therapy:
Psychotherapy
Cognitive behavioual therapy
Exposure Therapy
Systematic desensitisation and flooding
Applied relaxation
Social skills
Cognitive restructuring
Cognitive therapy
Interpersonal psychotherapy
Psychodynamic psychotherapy
Mindfulness