Brief role of the organization

Brief role of the organization

Bimla Devi Hospital stands as a crucial healthcare institution, delivering essential medical
services to individuals across diverse backgrounds. By incorporating mental health facilities,
including Shanti Home Advanced Deaddiction, Mental Health Clinic, and Psychiatric
Rehabilitation, along with an extensive array of healthcare services, our hospital is committed
to ensuring that patients receive top-quality care, fostering optimal health outcomes.

These resources are managed by mental health experts, including psychologists, psychiatrists,
and therapists who possess expertise in addressing various mental health conditions. Dr.
Manish Kansal is the head psychiatrist here and the interns in the psychology department
work under Dr. Palak Maheshwari who is a clinical psychologist there along with Ms.
Ananya who is the counselling psychologist. They deliver a comprehensive set of services,
encompassing individual and group therapy, medication management, and other evidence-
based treatment modalities.

Beyond mental health provisions, hospitals extend a diverse array of healthcare services,
including emergency care, surgical interventions, and both inpatient and outpatient
treatments. Additionally, they typically house diagnostic imaging and laboratory services, as
well as rehabilitation and physical therapy offerings.

Roles and responsibilities

• Conducting psychological assessments for patients- The goal was to assess their
mental health, identify potential disorders, and inform treatment planning. The
assessments included 16PF, MPQ, MAST, DAST among others.
• Making case histories and MSE of patients- this included detailed MSE after every
session conducted and elaborate case histories.
• Psycho-education of patients mainly of substance abuse was done along with case of
schizophrenia.
• Making reports and doing scoring of assessments conducted.
• Doing role plays and giving presentations for the topic given by supervisor- it helped
in simulating therapeutic or counselling scenarios to enhance clinical skills.
• Sitting in case history taking with family and observation in family sessions.
 CASE HISTORY- 1

Demographic Details

Name - Mr.S

Age - 27

Gender - Male

Education - B Tech Civil Engineering

Occupation - Architect

Marital status - Married

Chief Complaints

As reported by patient:

● “Mujhe gussa aa jata hai jaldi”

● “Mere bhot bade aspiration hai isliye vajha se bhi dikkat aati hai”

As reported by family member:

● These symptoms were from September 2022 on and off-

● Restless behaviour , Excessive planning , Decreased sleep

2 days before admission -

● Harming others , Religious talks

History of Present Illness (HOPI)

The patient was maintaining well before 3 days of admission. The patient from childhood
was living in Kanpur. He was an average student in class and liked to take part in
extracurricular activities. He was a favourite student of the teachers and had a group of
friends in school.

In class 12th he had failed in math which had affected him and he started to become alone
and away from the family he used to sit at one place for long. He also expressed that if
anyone had given him a glass of water he would sit with that glass of water for 2 to 3 hours
straight. He had visited and psychiatrist when he was in class 12 where he used to talk to him
the recovered.
He then pursued B.Tech while pursuing B.Tech he was in a relationship with a girl from class
9 who had broken up with him in 2nd year of B.Tech. At that time, he also felt very lonely
and used to stay aloof.

When he got married, he had come to Delhi to stay with his wife's parents as he felt that he
would get less opportunity in Kanpur where we had a paying job. He had got a job in live
space in Noida, which he had left after 1 month because he felt that less paying and he was
not joining the job as in Kanpur he used to work with big Businessman and had a control over
other workers whereas in live space he was an employee.

After leaving the job he had started to take big tenders for construction and calling everyone
for money.

The prominent symptoms of the patient came from the last 3 days. He started to become
aggressive, irritated, religious talks, harming others. An incident that was reported is that
when his mother came to meet, he was excited happy and started to cry after also had an
authority in voice while going for a drive he was driving really fast stating that this is done by
god bangling is head on the dashboard and stating that he see god in front of himself. Even
hit his wife whose 8 months pregnant. he didn't sleep from last three days he got violent with
his friends who came to meet him and even gets violent in night.

According to the patient he doesn’t remember anything that happened 3 days prior when he
came, he stated that he gets angry on small things, have high aspiration especially father
doesn’t understand as he is happy with small things and the son wants big things, he got
violent and was hitting others for which my family brought me here. He had also hit his
father -in-law. He also has financial issues with father, father used to nag him for 50 - 100 rs
which he didn’t like. That's why he shifted from Kanpur to Noida. The patient also said that
he has special powers, he can also do tandav and show how lord krishna and shivaji stand.
The patients stats that he had failed in class 12th which landed him in depression that time he
use to stay alone and sit at one place for very long period, also when he had broken up with
an 7 year long relationship he had went into depression.

Predisposing Factors- Temperament as a child, Precipitating Factors- Peer influence and

social company, Perpetuating Factors- Poor coping strategies, Positive attitude towards
substance use through peers, lack of family involvement, Protective Factors- Supportive
spouse and father.
Onset - Insidious

Course- Episodic

Progress - deteriorate

Past Psychiatric History

No past psychiatric history was reported.

Negative History

➔ No history suggestive of thinking (cognitive) and memory impairment.

➔ No history suggestive of loss of consciousness.
➔ No history suggestive of persistent, pervasive perceptual distortions of disturbance in
content of thought.
➔ No history suggestive of persistent, pervasive sadness of mood, loss of interest and
enjoyment and reduced energy.
➔ No history suggestive of anxiety evoked by certain well-defined situations or objects,
attacks of severe panic.
➔ No history suggestive of persistent pervasive intrusive thoughts or compulsive acts
➔ No history suggestive of episodes of repeated reliving of trauma and partial or
complete loss of the normal integration between memories of the past.
➔ No history suggestive of physical symptoms in spite of negative medical Findings.
➔ No history suggestive of body image distortions, persistent preoccupation with eating,
accompanied by purging.
➔ No history suggestive of excessive daytime sleepiness or lack of synchrony in sleep-
wake pattern
➔ No history suggests a pervasive persistent desire to be the opposite sex to that
assigned at birth.
➔ No history suggestive of subnormal intelligence.
➔ No evidence of loss from reality was observed.
➔ No persistent requests for doctors and medical examinations were reported or
➔ Observed.
 ➔ No evidence of binge eating or purging or excessive preoccupation with one's
physical appearance was observed.
➔ No evidence of arrested or incomplete development of the mind

Medical History

No Medical history reported.

Treatment History

The patient underwent multiple consultations with a psychiatrist in the past that has been
noted.

Family History

No case of illness present in the family as reported by the patient,patient stays with his wife
parents

27
yrs

Personal History

(i) Birth History: data could not be gathered due to absence of parents/guardians in the
session.

(ii) Educational History: he has completed B-tech in Civil Engineering, he was an average
student, he shared good relationships with his teachers and friends.

(iii) Occupational History: The reported that he has changed 2 jobs till now, and is currently
working at Live space as an Architect. He is on leave right now and will find a job in some
other company because he doesn't like the work environment.
Premorbid Personality

➔ Hobbies, areas of interest- He likes to play cricket.

➔ Attitude towards life- his attitude was positive towards life.
➔ Attitude towards Work and Responsibility: He was enthusiastic about his work life
and had a strong hold on his work. He also considered himself to be the family's only
earning person
➔ Attitude about self - he was positive that he can do things for his family and will
achieve everything.
➔ Attitude towards family and friends - He has cordial relationship with his mother,
his family relationship with his family was good, he even had good relationships with
his wife and friends.

Diagnostic Formulation

Patient named S aged 27 , male, came with complaints of aggression , harming others ,
excessive planning , religious talk , decreased sleep , talkative . He has a poor judgment and
got admitted involuntarily and has grade 3 insight

Mental Status Examination

General Appearance and Behaviour :

In the current situation, the patient is dressed casually. The patient is well-groomed, and his
hygiene is up to standard. He maintains proper eye contact throughout the session . The
patient was uncooperative while asking about the symptoms.

Psychomotor Activities -

It is seen that psychomotor activity was inadequate (increased), freedom of movement is

there and hand fidgeting is maintained throughout the session. Restlessness is also noticed
during the session.

Speech-
Patient speech is goal-directed, quality of speech is talkative and expensive , rate of speech is
fast , volume of speech strong , fluency is clear and Reaction time of speech is increased .
Mood and Affect:

Mood: “mai badiya feel kar raha hoon ek dam”

Evidence - “mere mood theek hai mujhe koi pareshani nahi ho rahi” ( i’m feeling okay and i
don’t feel any distress )

Affect: Elated mood

Evidence - mai bahut khush hu dekh raha hoga naa mai khush.

Perception

No perceptual distortion is reported in the current session.

Thought

Flow: The flow of thought is inadequate in the patient.

Form: Flight of ideas

Evidence- mujhe badi cheezo ka shauk hai , mai driver ke bina nahi reh sackta hu VIP se
milne jau toh late nahi ho sakta hai, isliye bhi mere papa se nahi banti hai kuki vo chote mai
khush hai, 50 ya 500 mai khush hote hai mai lakho ka sochta hu.

Content: The patient displayed-

Delusion of persecution-

Evidence - Jo yeh hai na “send me inside, I don’t like him” yeh spy hai

Delusion of grandiosity-

Evidence - mera utna beathna hai Rahul Gandhi ke sath, or ab lalu prasad yadav or rahul
gandhi chicken bana rahe hai youtube par video hai na vo mera idea hai , mere bina puche
kuch nahi karte hai vo,

“Rahul gandhi isse year ya next year PM bane ge toh mai unka right hand hoga”
“Mujhe driver ke sath hi jaunga kuki VIP se milta hu late nahi ho sakta”

“Mera bhot bade logo ke sath utna beathna hai”

“Kanpur mai jha job krta tha waah meri bhot achi baat chit thi merse bina puche kuch nahi
krte thay.”

Mere bahut bade aspiration hai mere papa mere thore mai khush hote hai mai vo nahi dekh
sackta hu.

Sensorium & Cognition: The patient is aware of time, place, and person.

Attention & Concentration: The remote attention is adequate, and the immediate attention
is intact. The patient was also able to maintain a high degree of concentration

General fund of Knowledge: The patient responded appropriately to basic general

knowledge questions.

Judgment:

Test judgment- has not been assessed in the current session.

Personal judgment- Adequate amount of self-care could be noted.

Social Judgment- Social relation and interaction is adequate in the patient.

Insight

level 3 - accepting that one is ill, but attributing it to some other external

or organic factors.

CBT Formulation

1. Cognitive Factors:

• Automatic Thoughts: Mr. S exhibits automatic thoughts related to his

aspirations, feeling misunderstood by his father, and the need for recognition.

NAT-

“I have to be a certain way and get good marks to get validation from parents.”

“I have to be loved.”
 • Core Beliefs: Deep-seated beliefs about the need for significant achievements
and his self-worth based on external validation may be contributing to his
distress.

2. Behavioural Factors:

• Aggressive Behaviour: Aggressive outbursts may function as a maladaptive

coping strategy to express frustration and gain control.

• Excessive Planning: Planning excessively may be an attempt to regain a sense

of control and certainty in his life.

3. Emotional Factors:

• Anger and Frustration: Mr. S struggles with managing anger, possibly

stemming from unmet aspirations and a sense of inadequacy.

Diagnosis: F30.2 Mania with psychotic symptoms.

Treatment:

- During the first 7 to 8 sessions general interaction with patients in order to understand
patient’s symptoms also patients were under medication so symptoms reduced day by
day.
- After the patient has developed a little insight about his then the psychoeducation
begins, in which the patient was started with educating about the triggers that would
increase his symptoms.
- There were sessions with his family members, and also individual sessions in
confronting the patient about the symptoms and helping him to find out ways to
reduce them.

Test Administration -

● On the first session with the patient in young mania rating scale which was for mania
i.e., 46 which falls under severe.
● After 7 sessions in young mania rating scale which was for mania i.e 32 which falls
under moderate.
 ● On the first session with the patient in Positive and negative syndrome scale done in
first sitting for positive symptoms – 45, negative symptoms- 15, composite score- -30,
general psychopathology- 56.
● After 7 sessions in Positive and negative syndrome scale done in first sitting for
positive symptoms – 43, negative symptoms- 14, composite score- -29, general
psychopathology- 49.

Multiphasic questionnaire

It is seen that the k-lie score is 2/4 which can be seen that the subject's answers are reliable,
he scored 10/5 in schizophrenia which signifies that the patient has symptoms like delusions,
suspicious towards others. Patient also scored 9/8 in paranoia; he may have symptoms of
hallucinatory voices. Patients scored 10/6 in mania may have symptoms like elevated mood,
increased physical and mental activity. In depression patients scored 6/5 he may have
symptoms like low mood, loss of interest. Hysteria score is 5/4, repression score is 9 <14,
patient is introverted and does not share his feelings with someone.
 CASE HISTORY- 2

Identification and demographics

Name: A

Age: 27 years

Sex: Female

Address: Agra

Domicile (rural/urban): Urban

Education: BA LLB

Occupation: Unemployed

Informant

Number of informants: 2

Relationship with patient: Sister and Father

Chief Complaints

A 27 year old women was brought by the informants with the chief complaints of - “Voh
manney lag gayi hai ki voh ek RAW agent hai”

“Yahi mante hue hume bolkr gayi thi Gurgaon jarhi hai and fir Srinagar se call aarha hai ki
beti ko lejao bahut unsafe hai vaha, use puchne par usne kaha ki voh apne mission ke liye
gayi thi”

“Sab par shakk karti rehti hai”

Client- “my father often misjudges me so I don’t know why he brought me here for
evaluation”

History of presenting illness

The history of the index patient dates back to 3 years back this was the time when she had
been studying for her BA LLB back papers, the pt. showed interest in studying for UPSC
examination. Since she was unable to clear the exams in the first place she shared this interest
of hers with her sister and told her desire to become a RAW agent. Since childhood she
enjoyed her own company and liked staying aloof she would spend her free time by reading
books and going for nature walks. She was close to her sister which still is the case.

The pt. after a few months of having study for UPSC told her sister as to not inform anybody
that she is a RAW agent. Earlier it was taken as a joke however, since that day she started
socially withdrawing herself more and viewed her parents as being judgy and viewed them
with suspicion. Later the belief strengthened and was unshakable, it became a part of her
identity which she hid from most of the people since it could not be disclosed to anyone.

She while watching television started to believe that when the prime minister was delivering
some speech that he was talking to her about some mission and that it was also a sign that a
new mission is to begin. There are times when two people are talking and she believes that
she is the one who is being talked about. She has great interest in reading news and articles.

The pt. believes that her parents do not understand her and she also says that her father is the
one who she does not like since he does not accept her for who she is, she also had filed an
FIR against her father. She recalls that in childhood her father had beat her up for something
trivial as inability to get the desired marks. She has often been criticized by him for not
getting the first position in class. Her suspiciousness as is seen to be on the rise she also
believes that cameras are fitted everywhere and she is to act in a certain way and she cannot
reveal everything to everyone. She is in a constant look out for the cameras. Due to this her
sleep is also decreased and is always on the look out for cues and signals.

However, all of this was not seriously taken up by her parents until she took an unplanned
trip to Srinagar to an unsafe area which alerted her parents. The pt. told the family that she
was going to Gurgaon for her college work and then disappeared for 4-5 days when the
parents got a call about her whereabouts in Kashmir. After this incident her sister whom she
is very close to when asked why did she go there she said that she had a mission in Kashmir
and she was told to go live with Muslim families. During this trip itself she threw her phone
away because she was told to do so as that would enable others to track her down.

There was a sense of joy she felt after completing the mission and there was a sense of relief
found in doing so. The mission information the pt. said she receives through hidden messages
like when she had been travelling with her parents, she told her sister that she has to leave
because a new mission has started and when asked how she got aware of this she said that a
green truck passed by and this is a signal for the same. Before coming to this setting, the
patient has gone to one other place for treatment where the psychiatrist gave anti psychotics
yet after that she carried out going to Srinagar which made them come to this set up. There is
complete denial of the presence of some illness and due to which there is low compliance to
medication.

Onset: Insidious Course: continuous Progress: deteriorating.

Past Medical history

None significant

Past Psychiatric History

None reported

Family history

The pt. lives in a nuclear family with mother, father and one younger sibling (1 sister). Pt. has
recently completed her BBA LLB and her sister is currently working for an organization in
Noida. The family is settled in Agra while the pt. lives with her sister in Noida at present but
earlier for her college she stayed in Gurgaon. She does not like staying with her family and
prefers being with her sister or alone in Gurgaon. During the college years also, she did not
visit the family often.

27

Family history of psychiatric/medical condition

None reported

Personal history

The pt. is born and brought up in Agra, she was a above average student in studies, after
passing out from school se enrolled in BA LLB course in a college in Gurgaon. She had
always been an introvert and liked to spend time by herself more than with others, she had
very limited friends and used to interact and meet with them once or twice in 2 months.

Diagnostic formulation
A, 27-year-old, unmarried Hindu female, presented with delusions of grandiosity and
reference along with suspiciousness since the past 3 years. MSE revealed euthymic mood and
affect with no perceptual disturbances, with guarded behaviour, adequate mental functioning
and level 1 insight.

CBT Formulation
A's upbringing was marked by a high emphasis on achievement and success home. Her father
enforced strict standards of achievement, and her self-worth was intricately tied to her ability
to meet these standards. Frequent criticism from her father for not achieving highly in various
activities and the pressure to come first in class at school had a significant impact on her self-
esteem. A's self-esteem was primarily shaped by her ability to meet these high standards.

Core Beliefs:

Conditional self-worth: A holds a core belief that her worth as a person is contingent upon her
ability to achieve success. If she does not achieve success, she considers herself worthless.

Success through hard work: A firmly believes that with immense effort and hard work, she
can achieve anything she sets her mind to.

Conditional Assumptions (If-Then Statements):

“If I am not completely successful, then I am worthless.”

“If I work very hard, then I can achieve anything.”

Critical Incident and Trigger:

While at university, A faced a situation where she worked hard but was not able to clear her
exams. This incident compromised her deeply ingrained rules for living and challenged her
self-esteem. A's fear of failure began to consume her, and she started to exaggerate the
likelihood of failing not only that module but also other aspects of her life. She experienced
NATs such as "I'm bound to fail the course" and "I'm letting my parents down." Her self-
worth crumbled as she perceived herself as worthless.

Negative Automatic Thoughts (NATs):

"I'm bound to fail the course."

"I'm letting my parents down."

In CBT, the therapist can work with A to challenge and restructure her core beliefs and
conditional assumptions. A cognitive restructuring process can help A recognize the
irrationality of her conditional self-worth and the all-or-nothing thinking that underlies her
beliefs. Techniques like cognitive restructuring, reality testing, and behavioral experiments
can be employed to help A develop a more balanced view of herself and her achievements.

Early experiences
High emphasis on achievement and success home.
Her father enforced strict standards of achievement, and her self-worth was intricately tied to her ability to meet
these standards.

Formation of rules of living and core beliefs

“If I am not completely successful, then I am worthless.”

“If I work very hard, then I can achieve anything.”

Critical Incident

Not able to clear her exams

Activation of rules for living and core beliefs

“If I am not completely successful, then I am worthless.”

“If I work very hard, then I can achieve anything.”

NATs

"I'm bound to fail the course."

"I'm letting my parents down."

Behaviour
Mood
Overworking
and assuming Anxious, hypervigilant
she is a raw
agent.
 Physical sensations

Tension, sleeplessness

MSE

General Appearance & Behaviour: A appears to be in her 20s. She presents herself in a
well-groomed and appropriate manner. She maintains eye contact during the interview. She
exhibited guarded behaviour. Rapport was established gradually.

Psychomotor activity: There are no signs of psychomotor agitation or retardation.

Speech: A's speech is coherent and goal-directed, with a normal rate of speech. She is able to
convey her thoughts and experiences in a clear and organized manner. The tone and pitch of
the pt. was adequate.

Mood and Affect: A's defined mood as “mei theek hu”, and her affect is euthymic which is
congruent with her mood.

Thought Process: A's thought process appears coherent and logical. She is able to provide
organized and sequential responses to questions. There is no evidence of thought blocking,
loosening of associations, or flight of ideas.

Thought Content: A exhibits delusions of grandiosity, believing she is a RAW agent. She
also experiences delusions of reference- “meine vaha dekha voh do log meri burai kr rahe
hai.” Delusion of persecution was aloso present “idhar kahi toh bhi aapne camer algaye hue
hai aur ab aap muje dekhoge muje sab pta hai.”

Perceptual Disturbances: There are no perceptual disturbances reported.

Cognition: A's cognitive functioning appears intact. She is oriented to time, place, and
person. Her memory, attention, and concentration seem adequate.

General fund of knowledge: Could not be elicited

Abstract reasoning: Abstract reasoning was adequate.

Insight and Judgment: A demonstrates level 1 insight into her condition. Her social
judgment is impaired, test and personal judgement is intact.
Diagnosis: F 20.9 Schizophrenia

Treatment:

- During the first 3-4 sessions general interaction with patients in order to understand
patient’s symptoms also patients were under medication so symptoms reduced day by
day.
- After the patient has developed a little insight about her condition then the
psychoeducation began, in which the patient was started with educating about the
provisional diagnosis given to her and explaining how she is not alone in the journey.
- There were sessions with his family members, and also individual sessions in
confronting the patient about the symptoms and helping her to find out ways to reduce
them.
 CASE HISTORY-3

Identification and demographics

Name: K

Age: 42 years

Sex: Male

Address: Pataudi

Domicile (rural/urban): Urban

Education: Graduate

Occupation: Unemployed

Informant

Number of informants: 3

Relationship with patient: Sister, Mother & Father

Chief complaints

“Raat mei achank yeh 2 din ke liye gayab hogya aur phone switch off krke rkhdia”

“Nahata nhi hai aur khata nhi hai kuch bhi”

“Baat krna bnd krdia hai akela rehna pasand krta hai”

History of presenting illness

The patient had been living independently in a PG in Delhi for six months, has been
brought to the clinical setting due to unusual and concerning behaviour. The chief complaints
include sudden outings for two days, switching off his phone, refusal to bathe, pacing around
at night, and displaying self-neglect. He has been described as disturbing to others in the PG,
leading to his removal from there. The PG owner had received several complaints from the
students as they were getting scared and even before him entering PG there had been odd
behaviour observed. He has been unemployed for several years and, despite staying with his
sister, his sister is however tired of him staying there since her in-laws have started to
complain. He does not like doing anything but likes to just sit and do nothing. He has a
history of social withdrawal and wandering behaviour. The onset of the illness is insidious
and course is progressive.

Onset: Insidious Course: progressive

Negative history

➔ No history suggestive of thinking (cognitive) and memory impairment.

➔ No history suggestive of loss of consciousness.
➔ No history suggestive of persistent, pervasive perceptual distortions of disturbance in
content of thought.
➔ No history suggestive of persistent, pervasive elevated mood, high self esteem and
increased energy.
➔ No history suggestive of persistent, pervasive sadness of mood, loss of interest and
enjoyment and reduced energy.
➔ No history suggestive of anxiety evoked by certain well-defined situations or objects,
attacks of severe panic.
➔ No history suggestive of persistent pervasive intrusive thoughts or compulsive acts
➔ No history suggestive of episodes of repeated reliving of trauma and partial or
complete loss of the normal integration between memories of the past.
➔ No history suggestive of physical symptoms in spite of negative medical Findings.
➔ No history suggestive of body image distortions, persistent preoccupation with eating,
accompanied by purging.
➔ No history suggestive of excessive daytime sleepiness or lack of synchrony in sleep-
wake pattern
➔ No history suggests a pervasive persistent desire to be the opposite sex to that
assigned at birth.
➔ No history suggestive of subnormal intelligence.
➔ No evidence of loss from reality was observed.
➔ No persistent requests for doctors and medical examinations were reported or
➔ Observed.
➔ No evidence of binge eating or purging or excessive preoccupation with one's
physical appearance was observed.
➔ No evidence of arrested or incomplete development of the mind
Medical history

None significant

Past Psychiatric History

None reported

Family history

The pt. lives in a nuclear family with mother, father and one younger sibling (1 sister). Pt. has
recently completed her BBA LLB and her sister is currently working for an organization in
Noida. The family is settled in Agra while the pt. lives with her sister in Noida at present but
earlier for her college she stayed in Gurgaon. She does not like staying with her family and
prefers being with her sister or alone in Gurgaon. During the college years also, she did not
visit the family often.

Family history of psychiatric/medical condition

None reported

Personal history

The pt. is born and brought up in Agra, she was a above average student in studies, after
passing out from school se enrolled in BA LLB course in a college in Gurgaon. She had
always been an introvert and liked to spend time by herself more than with others, she had
very limited friends and used to interact and meet with them once or twice in 2 months.

Diagnostic formulation

A, 27-year-old, unmarried Hindu female, presented with delusions of grandiosity and

reference along with suspiciousness since the past 3 years. MSE revealed euthymic mood and
affect with no perceptual disturbances, with guarded behaviour, adequate mental functioning
and level 1 insight

MSE

General Appearance & Behaviour: K appears to be in his 30s. She presents herself in a
well-groomed and appropriate manner. She maintains eye contact during the interview. She
exhibited guarded behaviour. Rapport was established gradually.

Psychomotor activity: There are no signs of psychomotor agitation or retardation.

Speech: A's speech is coherent and goal-directed, with a normal rate of speech. She is able to
convey her thoughts and experiences in a clear and organized manner. The tone and pitch of
the pt. was adequate.

Mood and Affect: A's defined mood as “mei theek hu”, and her affect is euthymic which is
congruent with her mood.

Thought Process: A's thought process appears coherent and logical. She is able to provide
organized and sequential responses to questions. There is no evidence of thought blocking,
loosening of associations, or flight of ideas.

Thought Content: A exhibits delusions of grandiosity, believing she is a RAW agent. She
also experiences delusions of reference- “meine vaha dekha voh do log meri burai kr rahe
hai.” Delusion of persecution was aloso present “idhar kahi toh bhi aapne camer algaye hue
hai aur ab aap muje dekhoge muje sab pta hai.”

Perceptual Disturbances: There are no perceptual disturbances reported.

Cognition: A's cognitive functioning appears intact. She is oriented to time, place, and
person. Her memory, attention, and concentration seem adequate.

General fund of knowledge: Could not be elicited

Abstract reasoning: Abstract reasoning was adequate.

Insight and Judgment: A demonstrates level 1 insight into her condition. Her social
judgment is impaired, test and personal judgement is intact.
 CASE HISTORY- 4

Demographic Details

Name - Mr.A

Age - 54

Gender – Male

Domicile- Delhi

Religion – Sikh

Education – Bachelor’s in Arts (B.A)

Occupation – business of motor spare parts.

Marital status - Married

Socio economic status - Middle class

Informant - Patient and parents

Chief Complaints

As reported by informant : Parents

“Alcohol dependency bohot hai”

“Bahut gussa aata hai peene ke baad aur bahut daaru peeta hai”

“Injection hafte me 2 baar leta hai jisse bhook bad jaati hai par uske alawa appetite decreased
hai”

History of Present Illness (HOPI)

The patient was born in the year 1969 in Delhi , during the joint he had shifted to Punjab for a
couple of years because of Sikh riots after which his family had come back to Khureji, Delhi,
at that point the patient was staying in a nuclear family. When he was 9 years he had suffered
and head injury which was not taken care seriously and was just given basic medical help.

During his school time he was bullied because of his height due to which he started to feel
inferior, then he decided to exercise rigorously and which caused injury in his spinal cord. In
class 11th and 12th, he was an average student. He didn't like to study that of like to Sing but
because of the family’s financial pressure he could not pursue his passion to support his
family financially.

He has a degree in Bachelors in Art. In college he has started consuming alcohol casually.
After bachelors he had started a business in 2002 for hair clips which had a good run for a
couple of years but had stopped because Chinese hair clips entered in the market which were
cheaper which resulted him to close his business. Then he started a business of local mobile
charger which had a good run but in 2011 new players were enter in the market and
advancement in technology were beginning which could not be matched by him so the
business had to be closed. He had suffered severe loss in the business which resulted his
increase in alcohol. He used to consume one quarter of alcohol every day.

In 2011 when he was going for his brother's marriage, he suffered a severe headache and felt
his body numb though he had recovered back. He started to have frequent headaches for
which he had visited several psychiatrists and underwent several medical tests but any cause
of illness was not found. When he was suffering with headache he would think that he is
intoxicated and to reduce that feeling he used to drink which resulted his increase in tolerance
he started with half quarter, then one bottle and then two bottles a day of whisky. He had also
suffered in an accident in 2011 which had injured his leg and he underwent an operation.

From 2011 to 2019 the habit of drinking alcohol had increased which had resulted in Loss of
interest in his occupation. In 2020 when COVID hit he used to drink regularly at home hiding
it from his family and even used to buy alcohol bottles paying extra money for them as it was
not easily available at that time. He had started spending extra on alcohol Bottles and
neglecting the family which resulted to hamper his relationship with the family. He was also
diagnosed with cirrhosis. Gradually two bottles a day was not giving him the feeling of
intoxication. He started to have a stomach ache for which the doctor had prescribed injections
of Phenylalanine, which gave him a feeling of relaxation. He started to take that injection
thrice a day. Due to these overdoses of alcohol and injections he was brought to the institute.

Predisposing Factors- Alcohol use in genetics, Precipitating Factors- Loss in company,

shutdown of business, Perpetuating Factors- Poor coping strategies, Positive attitude towards
alcohol and Protective Factors- No authority to stop him.

Onset - Insidious
Course- Continuous

Progress - deteriorating

Past Psychiatric and Medical History

No Past Psychiatric History was reported by the patient

The patient has been diagnosed with liver cirrhosis in March, 2020 before the first wave of
COVID-19 lockdown and he is under medications and treatment visits continuing at present.
He has also taken consultations from Institute of Liver and Biliary Sciences (ILBS). And due
to continual excessive drinking, his condition is currently deteriorating.

He is diabetes and Blood pressure issues from past 5-7 years

Family History/Genogram/Type- Joint Family, Siblings – 2

No case of illness presents in the family as reported by the patient.

54 yrs

Negative History

➔ No history suggestive of thinking (cognitive) and memory impairment.

➔ No history suggestive of loss of consciousness.
➔ No history suggestive of persistent, pervasive perceptual distortions of disturbance in
content of thought.
➔ No history suggestive of persistent, pervasive elevated mood, high self esteem and
increased energy.
➔ No history suggestive of persistent, pervasive sadness of mood, loss of interest and
enjoyment and reduced energy.
 ➔ No history suggestive of anxiety evoked by certain well-defined situations or objects,
attacks of severe panic.
➔ No history suggestive of persistent pervasive intrusive thoughts or compulsive acts
➔ No history suggestive of episodes of repeated reliving of trauma and partial or
complete loss of the normal integration between memories of the past.
➔ No history suggestive of physical symptoms in spite of negative medical Findings.
➔ No history suggestive of body image distortions, persistent preoccupation with eating,
accompanied by purging.
➔ No history suggestive of excessive daytime sleepiness or lack of synchrony in sleep-
wake pattern
➔ No history suggests a pervasive persistent desire to be the opposite sex to that
assigned at birth.
➔ No history suggestive of subnormal intelligence.
➔ No evidence of loss from reality was observed.
➔ No persistent requests for doctors and medical examinations were reported or
➔ Observed.
➔ No evidence of binge eating or purging or excessive preoccupation with one's
physical appearance was observed.
➔ No evidence of arrested or incomplete development of the mind
.

Personal History:

(i) Birth History: Born in Delhi, brought up partially in Delhi and Punjab

(ii)Educational History: He has completed his 12 class from an open school and graduated
in Bachelors of Arts in Punjab. He was an average student, he shared good relationships with
his teachers and claimed that he never had long term friends.

(iii) Occupational History: As per reported by the patient, he opened his first business in
1976, where he sold hairclips and less supplies of Patiala suits. This business hit a downfall
when Chinese clips came into the market with low prices. His next business was in 2003,
selling chargers which hit a downfall once specific type of chargers started hitting the
markets. He tried to extend partners in Bangalore and Coimbatore but led to losses of 5 lacs.
This downfall led to a gradual habit of excessive drinking. He is currently working with his
brother in his joint venture of making spare parts of automobiles.

Premorbid Personality

➔ Hobbies, areas of interest- Singing

➔ Attitude towards life- A positive and growing attitude towards life
➔ Attitude towards Work and Responsibility: He was enthusiastic about his work life
and had a strong hold and determination towards his work.
➔ Attitude about self -Positive attitude towards self-growth.
➔ Attitude towards family and friends - He has cordial relationship with his wife, his
family relationship is also good, he claims to have no Friends.

Diagnostic Formulation

Patient named Armeet Singh, age 54, male, came with complaints of excessive drinking and
high dependence on alcohol. He was noticed to be quite aggressive, having low appetite,
irritated and always intoxicated. He has a good judgment and got admitted voluntarily and
has grade 5 insight.

Mental Status Examination

General Appearance and Behaviour

The patient, who was identified as male appeared to be in his early 50’s. He was properly
dressed. He was interacting properly and was attentive during the session.

Motor Activity

The psychomotor activity appeared to be intact.

Speech

The patient’s speech appeared to be completely intact and understandable for the examiner.

Mood- Mood appeared to be good and he addressed that he is feeling great.

Affect -The patient was observed to be in the euthymic state. Which was congruent with his
mood.

Thought Content and Process.

The patient’s thought content and process could be elicited as normal flow, rate and reaction
time. There was normal thought content and no abnormal content was elicited

Perceptual Disturbances

No perceptual disturbances elicited.

Cognition

The patient appeared to have intact orientation.

Judgment

Test judgment- the patient is aware of personal responsibilities

Personal judgment- Self-care is adequate.

Social Judgement- Patient has adequate social interaction.

Insight

The patient’s insight is considered to be in Grade 5.

 CASE HISTORY -5

Demographic Details

Name - Mr. AS

Age - 39

Gender - Male

Domicile - Delhi

Education - Diploma in business management

Occupation - Healthcare recruiter

Marital status - Married

Socio economic status - Middle class

Family type - joint family

Siblings - 1

Informant - Patient

Chief Complaints

As reported by patient :

“ I had an accident few day before while riding a bike because of blackouts and now I’m
getting very frequently blackouts”

“I lost my connection with my family due to drugs and mai apne bacho ko wife ko time nahi
de pata hoon just because of drugs, fir jaldi hi mer bhai ki shaadi bhi hone wali hai toh mujh
ko sahi hona padega, what people will think”

History of Present Illness (HOPI)

The history of the index patient dates back when he was 13 years old and functioning well,
after which he started to consume alcohol occasionally but didn’t realize when it became
regular. The family knew about the habit of alcohol usage. He was an average student in class
12 and he used to drink everyday with his friends and not attend school as he used to take
alcohol everyday which also resulted in aggressive behaviour. After 12th class he went to
Australia to pursue a diploma in business management where he used to drink every day, he
even did various jobs there. On Christmas night he had a fight in an intoxicated state and
killed the person for which he was given punishment for 12 years but due to his good
behaviour he got parole after 9 years 1 week, when he heard news of his grandmother died
for which he couldn’t come back to India which according him lead to use of cocaine, heroin
by his friend in jail because he use to stay sad and substance use became a distraction.
gradually it become everyday usage alcohol, heroin and cocaine. When the patient came back
to India he used to use alcohol, cocaine and heroin together in a day which resulted in losing
his relationship with family and friends, he became more aggressive and used to stay with
people who used to use substances. He was getting away from his family and especially wife
and kids. He was not able to give them time and used to complain that the bosses in his job
were not good, rather he was there in an intoxicated state. In Sep 2023, he had taken his
neighbour’s bike in an intoxicated state and suffered a blackout and met with an accident. He
had left the bike and walked home with several bruises. He had lost his bike and due to some
misunderstanding the neighbour filed a case in the police station. The patient reported
increased on alcohol and usage of opioid and cocaine. He also reported experiencing
blackouts and sleep disturbance when he would stop drinking alcohol, cocaine and opioid. As
per patient he was alone in fighting from his intake of alcohol, cocaine and heroin. With these
concerns came to the current setup for further management.

Onset- Insidious

Duration- Since 13 years of age

Course- Continuous

Treatment History

The patient had been admitted to a rehabilitation centre in September 2022 for a month. The
patient had angry issues and destructive behaviour as reported by the family member.

Past Psychiatric and Medical History

No Past Psychiatric History was reported by the patient

The patient was also involved in a road accident recently in 2023, which caused several
bruises on his hand and leg. No head injury was reported.
Family History

No case of illness present in the family as reported by the patient.

3
9

Family Type- Joint Family

Authority Figure- Father

Current Social Situation- Middle Class

Attitude towards patient’s illness- Supportive

Religious Values- Sikh

Social Support System- Father and Wife

Negative History

➢ No history suggestive of thinking (cognitive) and memory impairment

➢ No history suggestive of head injury, loss of consciousness
➢ No history suggestive of persistent, pervasive perceptual distortions of disturbance in
content of thought
➢ No history suggestive of persistent, pervasive elevated mood, high self esteem and
increased energy
➢ No history suggestive of persistent, pervasive sadness of mood, loss of interest and
enjoyment and reduced energy
➢ No history suggestive of anxiety evoked by certain well defined situations or objects,
attacks of severe panic.
➢ No history suggestive of persistent pervasive intrusive thoughts or compulsive acts.
➢ No history suggestive of episodes of repeated reliving of trauma and partial or
complete loss of the normal integration between memories of the past
 ➢ No history suggestive of physical symptoms in spite of negative medical findings
➢ No history suggestive of body image distortions, persistent preoccupation with eating,
accompanied by purging
➢ No history suggestive of excessive daytime sleepiness or lack of synchrony in sleep-
wake pattern
➢ No history suggestive of pervasive persistent desire to be the opposite sex to that
assigned at birth
➢ No history suggestive of subnormal intelligence
➢ No history suggestive of qualitative abnormalities in reciprocal social interactions,
patterns of communication and repetitive repertoire of interests and activities
➢ No evidence of loss from reality was observed
➢ No persistent requests for doctors and medical examinations were reported or
observed
➢ No evidence of binge eating or purging or excessive preoccupation with one's
physical appearance was observed
➢ No disturbance in sleep was observed
➢ No evidence of arrested or incomplete development of the mind

Personal History:

(i) Birth History: Data could not be gathered due to absence of parents/guardians in the
session.

(ii) Educational History: He has completed a Diploma in business management, he was an

average student, he shared good relationships with his teachers and friends.

(iii) Occupational History: As per reported by the patient he used to work in australia where
he did various jobs like work in amazon, bars and various other. He came to India where he
started to work as a Healthcare recruiter currently working.

Premorbid Personality

Hobbies, areas of interest- He likes to watch cricket and love to ride a bike.

Attitude towards life- his attitude was positive towards life.

Attitude towards Work and Responsibility: He was enthusiastic about his work life and
had a strong hold on his work. He also considered himself to be the family's only earning
person

Attitude about self - he was positive that he can do things for his family and will achieve
everything.

Attitude towards family and friends - He has cordial relationship with his wife, his family
relationship is also good, he even had good relationships with friends.

Mental status examination

General Appearance and behaviour

The patient is in proper attire according to the setting and socioeconomic status and hygiene
is maintained by the patient. There is proper eye contact maintained by the patient. The
patient was cooperative and the patient was a little drowsy. The patient has bruises on his
hand and both legs. Sometimes he tries to crack jokes.

Psychomotor activity

It is seen that psychomotor activity was adequate.

Speech

Patient speech is coherent, fluency is adequate. Amount, pressure and rate of speech is
normal. The patient volume is normal and the tone is soft. Reaction time of speech is
adequate.

Cognitive Functioning
The patient is oriented about the place, time and date.

Thought and Content

The flow of the thoughts was adequate.

No abnormalities observed in form and content

Mood and affect

Mood described by the patient was “haan sab sahi hi hai bas yeh ghar bej de jaldi se.” Affect
–the Patient was irritated, restless and was in anger.
Perception disorder

No abnormalities noticed in current session

Judgment

Test judgment- the patient is aware of personal responsibilities.

Personal judgment- Self-care is adequate.

Social Judgement- Patient has adequate social interaction.

Insight

Level 5- Intellectual insight – attributing it to one’s own thought process.

Diagnostic Formulation

Patient Mr. AS, 39 years of age, married, educated with a diploma in business management
currently working as Healthcare recruiter living in a joint family setup located in urban Delhi
presented with the complaints of continuous use of alcohol, cocaine and heroin accompanied
with aggressive behaviour and low frustration tolerance. On MSE findings were restless and
irritated, adequate mental functioning and Grade 5 insight.
Monthly Reflections

The internship started in the month of August and the month of august was full of new
learnings and challenges. It went in understanding the system of the institution and what is
expected out of us. My initial interactions with fellow interns were enlightening, offering
insights into their diverse therapeutic approaches and expertise. One notable learning
opportunity was observing client intake sessions and participating in case discussions. This
allowed me to witness firsthand the application of various theoretical frameworks and
therapeutic modalities. Additionally, I began to develop a foundational understanding of the
client population served and the specific challenges they face. I also got to know what do I
have to do in the coming days such as case presentations, theoretical presentations and role-
plays. All of this was also introduced initially going to internships and deaing with diverse
patients was very hectic it still does get overwhelming at times but things have got better and
I feel that I am capable to push myself to do more.

As I progressed into the second month, I actively participated in conducting psycho-

educating the patients and this was the first time I was doing so with the guidance of the
supervisor. This was very insightful and during this time I was also in observation of
Rorschach conduction which again was very interesting and I had always wanted to see how
it is done. These experiences allowed me to integrate theoretical knowledge into practical
applications, refining my ability to adapt interventions based on the needs of diverse client
groups. Working with clients in therapy helped me realize how crucial it is to understand
different cultures and provide treatments tailored to each person. Trying out different
therapeutic methods also made me appreciate the subtle and complex aspects of
psychological interventions.

The last month was where I did not feel like leaving the internship because it became a part
of our routine and the job got more challenging and closely aligned to the work we are going
to do as budding psychologist. I was able to give session of MET to patient with substance
use. I actively sought opportunities to diversify my caseload, working with clients presenting
a range of psychological concerns.

The overall learning was also enhanced by the course of multicultural therapeutic skills that
was a part of the curriculum taking guidance about the cases and the next time visiting the
internship site implying those skills and learning aided the process of learning. Each month
has been instrumental in shaping my understanding of clinical psychology.