PSYCHODIAGNOSTIC RECORDS

M.PHIL. CLINICAL PSYCHOLOGY

DEPARTMENT OF CLINICAL PSYCHOLOGY

Submitted by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor & H.O.D
Trainee (2023-2025) (Course Coordinator)
Department of Clinical Psychology Dept of Clinical Psychology
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
 DECLARATION

I hereby declare that this " PSYCHODIAGNOSTIC RECORDS" is my work for the
fulfilment of my Degree in M.Phil. Clinical Psychology, offered by the Department of
Clinical Psychology of Sri Aurobindo Medical College and University. To the best of my
knowledge and belief, it contains no material previously published or written by another
person nor material which to a substantial extent has been accepted for the award of any other
degree or diploma of the university or other institute of higher learning.

Aashi Jhawar
M.Phil. Clinical Psychology
Trainee (2023-2025)
Department of Clinical Psychology
Sri Aurobindo University, Indore
 CERTIFICATE

This is to certify that the " PSYCHODIAGNOSTIC RECORDS" submitted by Ms. Aashi
Jhawar for the partial fulfilment of the Degree in M.Phil. Clinical Psychology, offered by the
Department of Clinical Psychology of Sri Aurobindo Medical College and University is an
original work carried out under my guidance.

Aashi Jhawar
M.Phil. Clinical Psychology
Trainee (2023-2025)
Department of Clinical Psychology
Sri Aurobindo University, Indore
 Sri Aurobindo Medical College and University, Indore, M.P.
Department of Clinical Psychology

CASE HISTORY No.: 1

OPD No.: 14461234

SOCIO-DEMOGRAPHIC DETAILS:

Name: P O

Age: 17

Gender: Female

Education: 11TH

Occupation: Student

Marital Status: N/A

Socio-economic Status: Middle

Locality: rural

Referred By: Department of Psychiatry

Informant: Family

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: The patient reports experiencing anger when others don't listen to her. She
sometimes struggles to breathe when she dissociates. During her first dissociative episode,
she saw her aunt, who passed away six years ago, and felt that her aunt was going to kill her.
When dissociated, she tends to bite her tongue. She prefers living in the dark and feels as
though her aunt's presence is inside her. She often sees her aunt sitting in a red saree,
threatening to kill her. Whenever the patient tries to study, she feels that her aunt interferes by
turning the pages, preventing her from concentrating. She has tried to self-harm.

Informant: According to the informant, three years ago, she lost consciousness and remained
unresponsive for three days. After that, she began experiencing dissociative episodes. During
these episodes, she would lock herself in the bathroom and attempt self-harm by cutting
herself and trying to choke herself. When dissociated, she becomes angry and physically
lashes out at others. She also constantly experiences a heavy sensation in her head.

HISTORY OF PRESENT ILLNESS (HOPI):

A 17-year-old female was brought to the OPD by her parents. According to the information
provided, three years ago, she lost consciousness and was hospitalized, regaining
consciousness after three days. Following this incident, she began experiencing dissociative
episodes. During these episodes, she bites her tongue, becomes aggressive, and physically
assaults others, as well as engages in self-harm.

On October 3rd of last year, she had a dissociative episode where she locked herself in the
bathroom and harmed herself by cutting and choking herself. She believes that her deceased
aunt (referred to as "chachi") is inside her and is trying to kill her. She often sees her
deceased chachi, dressed in a red saree, sitting and telling her that she will kill her. This
presence also prevents her from studying; whenever she attempts to study, she feels that her
chachi turns the pages of her books and questions why her uncle remarried. Her deceased
chachi had died by suicide.

Additionally, another of her aunts also experiences dissociative episodes. The patient
becomes angry when people do not listen to her and tends to act on her own impulses without
following others' guidance.

Onset: Insidious

Course: Chronic
Progress of illness: improving

Precipitating Factors: she got unconscious 3 years back and regained consciousness after 3
days.

Predisposing Factors: her aunt also gets dissociated.

Perpetuating Factors: Poor coping strategies.

Protective Factors: Support from family

Negative History: - no history suggestive of schizophrenia

- No history suggestive of paranoid personality.

PAST MEDICAL HISTORY: The patient got unconscious three years ago

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: One of her aunts experienced dissociative episodes and eventually
died by suicide, while another aunt also has dissociative episodes. And her brothe has a hole
in his heart and is deaf.
PERSONAL HISTORY:

Birth and Early Development: The patient was born at full term via C-section, weighing 2.5
kg. She had a normal birth cry, and her developmental milestones were typical.

Childhood History: Her childhood was marked by trauma, as both of her aunts experienced
dissociative episodes, with one eventually dying by suicide. Additionally, her brother was
born with a heart defect and is deaf, leading her to face numerous family challenges at a
young age.

Education and Schooling History: She is currently a 12th-grade student, pursuing the
science stream, and considers herself an average student.

Occupation History: she is a student studying in class 12th

Menstrual History: she started her menstrual cycle at the age

PRE-MORBID PERSONALITY:

Social Relations: She has a good relationship with her family and maintains a small circle of
friends.

Intellectual Activities, Hobbies and Use of Leisure time: In her free time, she enjoys
listening to music and studying.

Pre-dominant Mood of patient:

Character:

 Attitude towards Self: didn’t describe.

 Attitude to work or responsibility: she works hard to gets better grades in her
school
 Interpersonal relationships: The patient has a good relationship with her family, but
her limited number of friends
 Moral and religious attitudes and standards: she is religious and goes to temple
every morning.

Habits:

She has a normal appetite and sleep pattern.

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: her general appearance was typical and her attitude
towards the examiner was cooperative.

Psycho-Motor Activity: The patient’s psycho-motor activity seems to be affected during

dissociative episodes, where she engages in self-harm behaviours like cutting and choking
herself. Outside these episodes, her activity level isn't specifically detailed but may be within
normal limits.

Speech: during dissociative episodes, her speech may be impacted by her state of distress and
aggression.

Mood and Affect: The patient’s mood appears to be predominantly anxious and fearful,
particularly in relation to her experiences of dissociation and the presence of her deceased
aunt. Affect may be labile or inconsistent, especially during episodes of dissociation.

Thought:
  Stream: The patient’s thought stream might be disrupted during dissociative
episodes, with possible interruptions due to distressing thoughts or experiences.
 Form: There may be disorganized thought processes during episodes of dissociation,
with possible confusion or incoherence related to her belief in the presence of her
deceased aunt.
 Possession: The patient seems to feel that her thoughts or experiences are influenced
or controlled by her deceased aunt during dissociative episodes.
 Content: The content of her thoughts is heavily influenced by her fear of her
deceased aunt, including feelings of being threatened and interference in her daily
activities like studying.

Perception: The patient experiences distorted perceptions, specifically visual and possibly
auditory hallucinations involving her deceased aunt. This suggests significant perceptual
disturbances during dissociative episodes.

Cognition: Cognitive functions appear to be impacted by dissociative episodes, with possible

difficulties in concentration and memory, particularly related to her belief that her aunt
interferes with her studying.

Judgment: The patient’s judgment may be impaired during dissociative episodes, as

evidenced by self-harm behaviours and aggressive actions towards others. This impairment
suggests difficulties in assessing and responding to situations appropriately.

Insight: The patient’s insight into her condition appears limited. She experiences significant
distress and confusion related to her dissociative episodes and the belief that her deceased
aunt is influencing her, which suggests a lack of understanding of her symptoms and their
impact.

IMPRESSION: Dissociative Disorder F44

PSYCHOLOGICAL ASSESMENT:
Rationale for Psychological Assessment: the patient came in the with the complaint of
dissociation.

Areas to be Investigated: Evaluation for diagnostic clarification

Test Administered:
1- Rorschach- ink blot test

2- Sentence Completion test

3- Thematic Apperception test

Clinical Observation and test behaviour:

The person who came in appeared generally fine. They could maintain eye contact for a

reasonable duration, and their speech was normal. They were well aware of the current time,

place, date, and month. However, they expressed concern about being judged by the

psychologist during a test, despite reassurances that they weren't being judged. The individual

is consistently worried about their appearance and what others think of them. Despite these

concerns, their attitude towards the psychologist was positive, and a good rapport was easily

established.
RORSACHACH
Structural Summary:

Location Features Determinants Contents Approach

Zf= 24 Single H=1 I = W.D.Dd.Dd.Dd

ZSum=84 M= 1 (H) =1 II = Dd.D.D
ZEst = 81 FM =1 Hd = 0 III = D.D.D

m=0 (Hd)=0 IV = W.Dd

W=4 FC = 1 Hx = 0 V = W.Dd.Dd

D = 20 CF = 0 A= 21 VI =D.D
Dd = 13 C=1 Ad = 5 VII = D.D.Dd.W.DdS
S=1 Cn=0 (Ad)=0 VIII = Dd.D.D
DQ FC’=0 An=4 IX = D.D.D.Dd.Dd
+ = 20 C’F=0 Art=1 X = D.Dd.D.Dd.D.D.D
O =17 C’=0 Ay=0
V =1 FT=0 BT=0
V/+ =0 TF=0 Cg=0
T=0 CL=0
FV=0 Ex=0
VF=0 Fd=0
Blends: A,Na V=0 Fi=0 Special scores
FY=0 Ge=0 LVL1 LVL2
YF=0 Hh=1 DV=3 1
Y=0 Ls=0 INC=0 0
Fr=0 Na=1 DR=1 1
Rf=0 Sc=0 FAB= 0 0
FD=0 Sx=0 ALOG=0
F=34 Xy=0 CON=1
Id=2 Raw Sum 6= 7
(A)=0 Wgtd=21
(2)= 20
AB= 1 PHR=1
AG=0 GHR =1
Form Quality COP=0 MOR = 1
FQx MQual W + D=24 CP=0 PER=0
+=0 +=0 +=0 PSV=9
o=8 o=1 o=8
u = 24 u=0 u = 11
-=6 -=0 -=5

Ratios, percentages and Derivations

R = 38 L = 8.5
EB = 1:2 EA =3 EBPer = 0 FC: CF + C = 1:1 AG = 0
eb = 1:0 es = 1 D=2 Pure C = 1 a: p = 1:1
Adj es = 2 Adj D =1 SumC’: WsumC = 0:2 Human Cont. =2
P=4
FM = 1 SUMC=0 WSUMC=2 Afr =0.62 Pure H =1
m=0 SUMT=0 SUMC’=0 S=1 2AB+(ART+Ay) =3
SUMY=0 Blends: R =1:38 ISOLATED R=0.05
CP = 0 Zd=3

a: p = 1:1 Sum6 =7 XA% = 0.84 Zf= 24 3r + (2)/R =0.52

Ma: Mp =1:0 Lv2 = 2 WDA% = 0.79 W:D: Dd =4:20:13 Fr + rF = 0
Mor = 1 Wsum6 =21 X-%= 0.15 W:M = 4:1 SumV = 0
M- = 0 X+% = 0.21 DQ+ = 20 MOR = 1
Xu% = 0.63 DQv= 1 H: (H) + Hd + (Hd) =1:1

PTI = 1 DEPI = 1 CDI = 2 S-CON= . 2 HVI= No OBS= No

Interpretation
Findings suggest that the patient has very limited resources.

Scores suggest that the impact of the stress typically creates considerable interference in
some of the customary patterns of thinking or behaviour.

Findings also suggest that the impact of the situational stress is probably rather modest.

Scores also suggest that although the patient typically uses an ideational style involving delay
while keeping feelings in abeyance before reaching a decision, instances will often occur in
which feelings are permitted to merge more directly with thinking and contribute
significantly to decision.

Findings also signifies that the individual is less stringent about modulating emotional
discharge that are most adults. People such as this tend to be more obvious or intense in
expressing feelings than the average individual.

Scores indicates that the patient’s psychological organization is marked by immaturity.

People such as this often-manifest behavioural difficulties when they are confronted with
complex emotional situations.

Findings also suggest that the patient scans hastily and haphazardly, and often may neglect
critical bits or cues that exist in stimulus field.

Scores suggest that the patient has difficulties in shifting attention.

Findings also suggest that it is probable that the person tends to react quickly to reduce the
irritation created by the intrusion of peripheral thoughts.

Findings also suggest that thinking is likely to be seriously disturbed. When

conceptualization is impaired at this level, the reality testing of the individual is usually
marginal at best. Thinking tends to be disorganised, inconsistent, and frequently marked by
very flawed judgments. Bizarre conceptualization is not uncommon, and usually people such
as this are unable to contend with the demands of everyday living in ways that will be
persistently effective.

Scores also suggest that the individual tends to be much more involved with themselves.

Findings suggest that some unusual body concerns or preoccupation is present.

Test Impression:
The assessment indicates that the patient is facing significant challenges with limited
resources. Stress seems to have a considerable impact on their usual thought and behavior
patterns, though the situational stress itself appears to have a modest effect. The patient often
adopts a thinking style that involves delaying decisions while keeping emotions in check, but
there are instances where feelings directly influence decision-making.

DIAGNOSTIC FORMULATION:

Points in Favour:

Dissociative Episodes: The patient experiences episodes of dissociation where she engages in
self-harm and has aggressive outbursts.

Perceptual Disturbances: The patient reports seeing and feeling threatened by her deceased
aunt, suggesting hallucinations or intense delusions.

Traumatic Background: A history of family trauma, including the suicide of an aunt and
ongoing health issues within the family, which may contribute to her psychological
symptoms.

Self-Harm Behaviours: The patient has engaged in self-harm during dissociative episodes,
indicating severe emotional distress.

Points in Against:

Normal Sleep and Appetite: The patient has normal eating and sleeping patterns, which may
suggest some stability in her overall functioning.

Normal Development: The patient’s developmental milestones were normal, which may
indicate that the current symptoms are more related to recent trauma and psychological stress
rather than a developmental disorder.

PROGNOSIS: The prognosis depends on various factors, including the effectiveness of

treatment and the support system available. With appropriate psychological and psychiatric
intervention, the patient’s symptoms may improve. However, the presence of severe
dissociative symptoms and perceptual disturbances suggests that ongoing treatment and
support will be crucial for managing her condition and improving her overall functioning.
DIFFERENTIAL DIAGNOSIS:

Dissociative Identity Disorder (DID): Given the presence of dissociative episodes and
perceived presence of the deceased aunt, DID could be considered.

Post-Traumatic Stress Disorder (PTSD): The traumatic experiences and symptoms like
flashbacks and emotional distress could be indicative of PTSD.

Schizophrenia or schizoaffective disorder: The perceptual disturbances (hallucinations) and

significant distress could suggest these conditions, though the primary symptoms are more
consistent with dissociation.

Borderline Personality Disorder (BPD): The self-harm, emotional instability, and

interpersonal difficulties might align with BPD, though it would need to be assessed
alongside dissociative symptoms.

MANAGEMENT PLAN:

Psychotherapy:

Cognitive Behavioural Therapy (CBT): To address dissociative symptoms, self-harm

behaviours, and maladaptive thoughts.

Trauma-Focused Therapy: To process and work through the traumatic experiences and
family history.

Dialectical Behaviour Therapy (DBT): To help manage emotional regulation and reduce self-
harm behaviours.

Medication:

Consider medications to manage symptoms of anxiety, depression, or other related conditions

as prescribed by a psychiatrist.

Support System:

Involve family therapy to improve family dynamics and support the patient.

Encourage participation in support groups or community resources for additional support.

Coping Strategies:
Develop and practice coping strategies to handle dissociative episodes and manage stress
effectively.

Regular Monitoring:

Schedule regular follow-ups to monitor progress, adjust treatment as needed, and address any
emerging issues.

Safety Planning:

Develop a safety plan for managing self-harm urges and ensure the patient has access to
emergency support if needed.

Assessment done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.: 2

OPD No.: 14425122

SOCIO-DEMOGRAPHIC DETAILS:

Name: V M

Age: 19

Gender: Male
Education: B.Tech

Occupation: Student

Marital Status: N/A

Socio-economic Status: Upper Middle

Locality: Sub-urban

Referred By: Self

Informant: Father

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “padhne mai mann nahi lagta”

“subha uthta hu toh padhaii ka pressure aa jata hai, aur jese padhne bethta hu toh pressure aa
jata hai aur phr so jata hu”

Informant: “2021 mai depression diagnosi hua tha, treatment hua tha but abhi vps se badh
gaya h”

“2023 mai unconscious hua tha toh 24 hr tk consciousness regain hui”

HISTORY OF PRESENT ILLNESS (HOPI):

A 19-year-old male patient visited the outpatient department accompanied by his father and
brother. He was diagnosed with depression in 2021 and underwent treatment that initially
helped improve his condition. Despite this, on July 4, 2023, he took some medication, which
led to him losing consciousness. He remained unconscious for approximately 24 hours.

The patient tends to isolate himself and has very few friends. He experiences considerable
stress and pressure related to his studies. Although he attempts to engage in studying by
setting goals and starting work, the pressure he feels is overwhelming. This stress often
causes him to become fatigued, leading to him falling asleep during his study sessions.

Onset: episodic
Course: acute

Progress of illness: fluctuating

Precipitating Factors: Overall, Health: His previous history of depression and current mental
state contribute to his susceptibility to further episodes.

Age: As a young adult, he may be experiencing transitional stressors related to personal

development and future planning.

Environmental Factors: Limited social support and high academic pressure are significant
predisposing factors.

Predisposing Factors: Overall, Health: His previous history of depression and current mental
state contribute to his susceptibility to further episodes.

Age: As a young adult, he may be experiencing transitional stressors related to personal

development and future planning.

Environmental Factors: Limited social support and high academic pressure are significant
predisposing factors.

Perpetuating Factors: Lack of Supportive Relationships: His preference for isolation and
limited number of friends could be contributing to his ongoing difficulties.

Academic Pressure: The stress associated with his studies seems to perpetuate his depressive
symptoms.

Poor Coping Strategies: The tendency to fall asleep when overwhelmed by study pressure
suggests inadequate coping mechanisms.

Lack of Social Support: The few friendships and potential lack of a supportive social network
may worsen his mental state.

Protective Factors: Family Support: The presence of his father and brother suggests some
level of familial support, which could be beneficial.

Previous Treatment Response: The initial positive response to treatment indicates that
effective interventions are possible.

Personal Insight: His awareness of his struggles and attempts to study despite the pressure
show some level of personal resilience.
Negative History: - no history suggestive of acute illness

- No history suggestive of chronic medical condition

PAST MEDICAL HISTORY: he took some medication, which led to him losing
consciousness. He remained unconscious for approximately 24 hours.

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: not significant

PERSONAL HISTORY:

Birth and Early Development: the patient was born in 8 months and his weight was 3.5 kgs.
Birth cry was present and his developmental history is typical

Childhood History: he had a normal childhood with a supportive family.

Education and Schooling History: he is currently doing BTECH but his education was on
hold for a year.
Occupation History: student

PRE-MORBID PERSONALITY:

Social Relations:

The patient has a supportive family

Intellectual Activities, Hobbies and Use of Leisure time: The patient engages in studying
but finds it stressful. Outside of academic pursuits, he prefers to spend time alone and does
not have mentioned hobbies or leisure activities.

Pre-dominant Mood of patient: The predominant mood is stressful and overwhelmed,

particularly in relation to academic pressures. This mood contributes to his depressive
symptoms.

Character:

 Attitude towards Self: The patient’s attitude towards himself may be affected by
self-doubt and stress
 Attitude to work or responsibility: He shows a strong sense of responsibility
towards his studies but struggles with the pressure, leading to fatigue and sleep during
study attempts.
 Interpersonal relationships: His relationships are limited, with a preference for
isolation. This could indicate difficulties in forming and maintaining close
interpersonal connections.
 Moral and religious attitudes and standards: There is no specific information
provided about his moral or religious attitudes, which could play a role in his coping
mechanisms and support systems.

Fantasy life: There is no information provided

Habits: his appetite is normal and sleep Is regulated

 MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: his general appearance was normal and behaviour
towards examiner was positive.

Psycho-Motor Activity: The patient displays signs of low psycho-motor activity, potentially
characterized by lethargy and fatigue, especially during study sessions. This may include
reduced physical movement or slower response times.

Speech: the patient’s speech was slowed or reduced due to his depressive symptoms

Mood and Affect: Mood: The predominant mood appears to be depressed, with stress
related to academic pressures.

Affect: The affect might be flat or restricted, reflecting his internal emotional state of feeling
overwhelmed and fatigued.

Thought:

 Stream: The thought stream may be slowed or interrupted due to depressive

symptoms and academic pressure.
 Form: coherent but with difficulties in concentration due to stress.
 Possession: There is no indication of thought possession or obsessions from the
provided information.
 Content: The content of thoughts likely includes academic stress and feelings of
being overwhelmed, which are central to his depressive symptoms.

Perception: No specific perceptual disturbances are mentioned. The focus remains on mood
and cognitive aspects rather than perceptual abnormalities.
Cognition: exhibit impaired concentration and difficulty in sustaining attention due to
depressive symptoms and stress related to studies.

Judgment: The patient's judgment may be affected by his depressive state, as evidenced by
the recent incident of unconsciousness following medication ingestion. This could indicate
impaired decision-making or coping strategies.

Insight: The patient appears to have some level of insight into his condition, as he recognizes
the stress related to his studies and the impact on his ability to study effectively.

IMPRESSION: Major Depressive Disorder F32. 9

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment: came in with the history of depression

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
• Sentence Completion Test (SCT)

• Thematic Apperception Test (TAT)

• Rorschach Ink Blot Test (ROR)

• Minnesota Multiphasic Personality Inventory (MMPI)- 3

 The TAT was administered individually in a quiet and comfortable testing room. Before

the administration of the TAT, a Sentence Completion Test (SCT) was administered

then was presented with a series of 10 TAT cards. He was asked to create a story based

on each picture. he was given no time limit for each card, and the instructions were

provided in a clear and concise manner. Next, he was given Rorschach cards and

instructed to articulate what he perceives in the inkblots.

Behavioural observations: He presented an overall neat and well-groomed appearance. He

demonstrated awareness of his surroundings and maintained proper eye contact. His attitude

towards the examiner was reasonably cooperative, and a rapport was successfully established.

While initially struggling to form sentences during the SCT, he eventually completed the test.

His speech exhibited audible intensity with a normal speed.

Test Findings:

Sentence completion Test (SCT)

The SCT assessment indicates that the individual experiences significant discomfort in social
situations, often becoming nervous when confronted with them. The patient struggles to cope
with pressure and exhibits persistent concerns about their future and career. There is a belief
that they are unable to meet their potential in tasks. The SCT assessment also reveals the
presence of anger issues. The patient tends to overthink, has difficulty managing stress, and
grapples with trust issues. To avoid confronting situations, the individual sleeps.

Thematic Apperception Test

Integrated Summary of the test-

• Main Theme: The main theme of the story revolves around

Achievement, anxiety and Relationship conflict with family members.

• Main Hero: The main hero of the story was a male and can be
identified with
 Self.

• Intellectual level: The narrative plots lacked structure, authenticity,

and completion, appearing disorganized and insufficient. The stories lacked

proper organization and exhibited a level of imagination that was below

satisfactory, indicating a less advanced intellectual capability in the subject.

• Emotional maturity: The patient’s emotional maturity is in

accordance to his age and sex.

• Personal adjustment: His personal adjustment is satisfactory.

• Social Adjustment: he has good interpersonal relations with family

members.

• Needs of the Hero: The dominant needs of the hero are need for

succorance, nurturance, dejection, aggression, achievement and elation

• Significant conflicts: Conflicts relating to achievement, family

relationship, emotionality,

• Nature of Anxieties: The main nature of anxieties was lack of support,

emotional understanding.

• Main Defenses: significant defence was found to be rationalization

and projection.  Ego-structure: Fear, anxiety and sadness are present in his

inner dynamics.

• Basic personality: The dominant traits of the hero are emotionality

and anxiety ridden.

Test Impression:

The narratives suggest variability in the patient's ability to identify with the hero, being

adequate in some instances and inadequate in others. The self-portrayal reflects a sense of

fear, anxiety, and stress within interpersonal relationships. Certain stories indicate the
patient's needs for nurturing, support, love, and stable healthy relationships. Academic

success and achievement also emerge as needs in some narratives, while others reveal

elements of aggression, dejection, and elation.

Overall, the stories point to conflicts in interpersonal relationships and highlight the patient's

need for support and family-related anxieties. The findings suggest a desire for love,

protection, and a pursuit of a peaceful life. The overarching themes centre around anxiety,

low self-esteem, a confused sense of self-worth, and challenges in relationships. The primary

sources of anxiety appear to be a lack of support and emotional understanding. The dominant

characteristics of the hero in these narratives are characterized by anxiety and emotional

struggles.

Rorschach Ink Blot Test

Structural Summary:

Location Features Determinants Contents Approach

Zf= 15 Single H=0 I=D
ZSum=54 M= 3 (H) =2 II = Dd.D
ZEst = 49 FM =4 Hd = 0 III = D.D.D Pairs(2)= 11
m=0 (Hd)=1 IV = W Blends=Ls,A
W=4 FC = 2 Hx = 0 V=W
D = 16 CF = 1 A= 5 VI =W.W
Dd = 1 C=1 Ad =0 VII = D.D
S=0 Cn=0 (Ad)=0 VIII = D.D
DQ FC’=0 An=0 IX = D.D.D
+ = 11 C’F=0 Art=0 X = D.D.D.D
O =7 C’=0 Ay=0
V =2 FT=0 BT=0
V/+ =1 TF=0 Cg=0
T=0 CL=0
 FV=0 Ex=0
VF=0 Fd=0
V=0 Fi=0 Special scores
FY=0 Ge=0 LVL1 LVL2
YF=0 Hh=0 DV=0 2
Y=0 Ls=2 INC=1 1
Fr=0 Na=2 DR=0 0
Rf=0 Sc=1 FAB=0 1
FD=0 Sx=0 ALOG=0
F=10 Xy=2 CON=3
Id=1 Raw Sum 6=8
(A)=2 Wgtd=38
Bl=1
AB= 0 PHR=3
AG=1 GHR =0
Form Quality COP=1 MOR = 0
FQx MQual W + D=20 CP=0 PER=0
+=0 +=0 +=0 PSV=4
o=6 o=2 o=6
u = 10 u=1 u=9
-=5 -=o - =5
Ratios, percentages and Derivations
R = 21 L = 0.90

EB = 3:3.5 EA =6.5 EBPer = 0 FC: CF + C = 2:2 AG = 1

eb = 4:0 es = 4 D = 2.5 Pure C = 1 a: p = 5:2
Adj es = 4 Adj D =2.5 SumC’: WsumC = 0:35 Human Cont. =3
P=1
FM = 4 WSUMC=0 Afr =0.75 Pure H =0
m=0 SUMT=0 SUMC’=0 S=0 2AB+(ART+Ay) =0
SUMY=0 Blends: R =1:21 ISOLATED R=0.28
CP = 0 Zd=5

Sum6 =8 XA% = 0.76 Zf= 15 3r + (2)/R =0.52

Ma: Mp = 1:2 Lv2 = 4 WDA% = 0.75 W:D: Dd =4:16:1 Fr + rF = 0
Mor = 0 Wsum6 = 38 X-%= 0.23 W:M = 4:3 SumV = 0
M- = 0 X+% = 0.28 DQ+ = 11 MOR = 0
Xu% = 0.47 DQv= 2 H: (H) + Hd + (Hd) =0:3

PTI = 2 DEPI = 3 CDI = 3 S-CON= 1. HVI= yes OBS= yes

Interpretation

Findings suggests that the patient is experiencing some kind of stress. It also suggests that the
impact of situational stress is rather modest.

The patient is prone to mix feelings with thinking much of time when coping is required.
Scores also suggests that although patient uses an ideational style involving delay while
keeping feelings in abeyance before reaching a decision, instances will often occur in which
feelings are permitted to merge more directly with thinking and contribute significantly to
decision.
Individual seems as willing as most others with their particular coping style to process and
become involved with emotionally toned stimuli. Generally, this is not a significant finding
but, if the person tends to have persistent difficulties with the modulation or control of
emotion it may indicate a naïve lack of awareness concerning those problem.

It can be assumed that the patient modulates emotional discharge about as much as other
adults most of the time.

Findings indicates the presence of overincoprative style. Overincoperation is an enduring

trait-like style that includes the exertion of more effort in scanning activities.
Scores also suggest that the patient has problem in shifting attention.

Findings also indicates significant meditational impairment or disfunction.

Patient rely heavily on conceptual thinking. They are inclined to think things through and
delay behaviour until they have considered various options. They are prone to trust internal
evaluation more than external feedback.

Findings suggest that the ideational sets and values of the individual are well fixed and
relitavely infixeable.

A positive HVI signifies the presence of a trait-like feature that tends to play a important role
in the psychology of the individual and often has significant impact on conceptual thinking.
Hypervigilant people use considerable energy to maintain a continuous state of preparedness.
This anticipatory or hyperalert state related to a negative or mistrusting attitude towards the
environment that evolves during the developmental years.

The patient might have avoidant coping style.

Findings indicates that that the person has a distinct tendency to defensively substitute
fantasy for reality in stressful situations more often than do most people. This can be a very
effective defensive strategy and should not be considered as a liability unless other evidence
indicates that the person is markedly dependent on others.

Scores signifies that thinking is likely to be seriously disturbed.

Test Impression:

The findings suggest that the patient is experiencing stress, but the impact of situational stress
is modest. The individual tends to intertwine feelings with thinking during coping, often
delaying decisions and allowing emotions to contribute significantly. While the patient is
generally willing to engage with emotionally toned stimuli, persistent difficulties in emotion
modulation may indicate a lack of awareness.
There is an overincoprative style present, involving increased effort in scanning activities,
and difficulties in shifting attention. Significant meditational impairment is noted, with a
heavy reliance on conceptual thinking, internal evaluation, and fixed ideational sets and
values.
A positive Hypervigilance Index (HVI) implies a trait-like feature impacting the individual's
psychology, involving a continuous state of preparedness and a negative or mistrusting
attitude towards the environment. The patient may exhibit an avoidant coping style.

Additionally, there is a distinct tendency to defensively substitute fantasy for reality in

stressful situations, which can be effective unless marked dependence on others is evident.
Overall, the scores suggest a likelihood of seriously disturbed thinking.

Test Findings on MMPI-3:

SCALE T-SCORE INTERPRETATION

CRIN (Combined Response 120 The protocol is uninterpretable.

Inconsistency)
VRIN (Variable Response 120 The protocol is uninterpretable.
Inconsistency)
TRIN (True Response Inconsistency) 120 The protocol is uninterpretable.

F (Infrequent Responses) 69 No Concerns

Fp (Infrequent Psychopathology 76 Insistent. Overreporting.

Responses)
Fs (Infrequent Somatic Responses) 58 No Concerns

FBS (Symptom Validity Scale) 70 No concerns.

RBS (Response Bias Scale) 72 No Concerns

L (Uncommon Virtues) 56 No Concerns

K (Adjustment Validity) 65 Inconsistent responding

HIGHER-ORDER (H-O) SCALES

Emotional/Internalizing Dysfunction 73 Indicate emotional distress.
(EID)
Thought Dysfunction (THD) 49 No concerns
Behavioural/Externalizing 42 Unlikely to engage in externalizing and acting
Dysfunction (BXD) out behaviour.

RESTRUCTURED CLINICAL (RC)

SCALES
Demoralization (RCd) 74 Reports:
Experiencing significant demoralization
Feeling overwhelmed
Being extremely unhappy, sad and dissatisfied
with his life.
55 Sense of physical well-being.
Somatic Complaints (RC1)
Low Positive Emotions (RC2) 75 Reports:
Pessimistic, socially introverted, socially
disengaged, lacks energy.
Displays vegetative symptoms of depression.
Antisocial Behaviour (RC4) 44 Below average level of past antisocial
behaviour
Ideas of Persecution (RC6) 70 Significant persecutory ideation such as
believing that others seek to harm him or her

Dysfunctional Negative Emotions 52 Reports below average level of negative

(RC7) emotional experiences.
Aberrant Experiences (RC8) 49 no concerns
Hypomanic Activation (RC9) 36 no concerns
SOMATIC/COGNITIVE SCALES

Malaise (MLS) 59 Reports generalised sense of physical well

being

Neurological Complaints (NUC) 47 No concerns.

Cognitive Complaints (COG) 57 no concerns

Eating Concerns (EAT) 56 no concerns

INTERNALIZING SCALES

Suicidal/Death Ideation (SUI) 58 History of suicidal ideation or past history of

attempts.
Helplessness/Hopelessness (HLP) 65 Reports helpless or hopeless or pessimistic

72 Reports self-doubt and futility

Self-Doubt (SFD)
Inefficacy (NFC) 72 Reports being passive, indecisive and
efficacious.
Stress (STR) 76 Reports multiple problems involving stress and
feeling nervous.
Worry (WRY) 54 Below average level of worry
Compulsivity (CMP) 56 No concerns
Anxiety-Related Experiences (ARX) 48 Reports a below average level of anxiety
related experiences

Anger Proneness (ANP) 49 No concern

Behaviour-Restricting Fears (BRF) 56 No concern

EXTERNALIZING SCALES
Family Problems (FML) 51 conflict free family environment

Juvenile Conduct Problems (JCP) 39 No concerns

Substance Abuse (SUB) 52 No concerns
Impulsivity (IMP) 52 Below average level of impulsive behaviour
Activation (ACT) 41 Reports below average level of energy and
activation
Aggression (AGG) 39 No concerns

Cynicism (CYN) 47 Describes other as well-intoned and trust

worthy
INTERPERSONAL SCALES
Self-Importance (SFI) 40 Describes himself as lacking positive qualities,

Dominance (DOM) 34 No concerns

Disaffiliativeness (DSF) 58 Being passive and submissive, not liking to be
in charge, ready to give in to others
Social Avoidance (SAV) 71 Avoiding social events and not enjoying social
events

Shyness (SHY) 55 Little or no social anxiety

PERSONALITY
PSYCHOPATHOLOGY FIVE
SCALES
(PSY-5)
Aggressiveness (AGGR) 31 no concern

Psychoticism (PSYC) 52 unusual belief and perception

 Disconstraint (DISC) 43 Overly constrained behaviour

Negative Emotionality/ Neuroticism 76 An elevated level of negative emotionality

(NEGE) Anxiety, insecurity, worry, is inhibited
behaviourally because of negative emotions,
self-critical and guilt prone, experience
intrusive ideation
Introversion/Low Positive 81 Reports a lack of positive emotional
Emotionality (INTR) experiences, avoiding social situation

MMPI-3 INTERPRETATION

Protocol Validity. Mr Vaibhav scores indicate that he has provided scorable responses to 334
test items. The protocol is invalid because of excessive response inconsistency, possible
reasons could be errors in recording responses, reading or language limitations, or cognitive
impairment. There is also some evidence of fixed, content inconsistent responding which
could mean difficulties with double negatives. There is an indication of overreporting. Also
underreporting which could mean that her upbring has been traditional. In the light of above-
mentioned results, clinical correlation must be sought after to corroborate and justify the
findings.
Report indicate Experiencing significant demoralization, feeling overwhelmed, Being extremely
unhappy, sad and dissatisfied with his life.
Reports Pessimistic, socially introverted, socially disengaged, lacks energy. Displays vegetative
symptoms of depression.

Significant persecutory ideation such as believing that others seek to harm him or her.
The patient reports sense of well-being.

The patients report history of suicidal ideation or past history of attempts.

The patient reports feeling helpless, hopeless, or pessimistic. The patient also reports feeling self-
doubt and futility. The patient has multiple problems involving stress and feeling nervous.

The patients describe himself as lacking positive qualities, lack of positive emotional experiences,
avoiding social situation

The patient reports being passive and submissive, not liking to be in charge, ready to give in to others.

The patient is introvert as he does not enjoy social gathering or being in one.

Reports indicates an elevated level of negative emotionality, Anxiety, insecurity, worry, is inhibited
behaviourally because of negative emotions, self-critical and guilt prone, experience intrusive ideation

Test Impression:

The individual in question is currently experiencing significant demoralization and feelings of being
overwhelmed, manifesting extreme unhappiness and dissatisfaction with life. They exhibit pessimism,
social introversion, and disengagement, lacking energy and displaying vegetative symptoms of
depression. The person harbours significant persecutory ideation, believing others intend to harm
them, despite reporting a sense of well-being. There is a history of suicidal ideation or attempts,
coupled

with feelings of helplessness, hopelessness, and pessimism. The individual expresses self-doubt,
futility, and nervousness, describing themselves as lacking positive qualities and avoiding social
situations. They portray passivity and submissiveness, preferring not to be in charge and being ready
to yield to others. The person is introverted, disliking social gatherings, and exhibits elevated negative
emotionality, including anxiety, insecurity, and worry. Their behaviour is inhibited due to negative
emotions, and they are self-critical and prone to feelings of guilt, experiencing intrusive ideation

DIAGNOSTIC FORMULATION:

Points in Favour:

History of depression with prior treatment response.

Recent medication overdose indicates severe distress.

Difficulty managing academic pressure aligns with depressive symptoms.

Points in Against:

No clear evidence of substance abuse beyond the recent incident.

No psychotic symptoms or significant perceptual disturbances noted.

PROGNOSIS: The prognosis may vary depending on the effectiveness of interventions.

With appropriate treatment and support, the patient’s condition can improve. However,
ongoing stressors and inadequate coping strategies might affect recovery.

DIFFERENTIAL DIAGNOSIS: Generalized Anxiety Disorder (GAD): Could overlap with

stress and academic pressure but typically involves more generalized anxiety.

Bipolar Disorder: To be considered if there are mood swings or manic episodes not described
here.

Adjustment Disorder: If symptoms are directly related to academic stress without a history of
recurrent depressive episodes.

MANAGEMENT PLAN:

Medication: Review and adjust antidepressant medication, if necessary, under psychiatric

supervision.
Psychotherapy: Cognitive-behavioural therapy (CBT) or other therapeutic approaches to
address stress, coping mechanisms, and depressive symptoms.

Stress Management: Techniques to manage academic pressure, such as time management

strategies and relaxation exercises.

Social Support: Encourage building a supportive social network and engage in social
activities.

Assessment done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.: 3

IPD No.: 938333

SOCIO-DEMOGRAPHIC DETAILS:

Name: S K

Age: 35
Gender: Male

Education: BA

Occupation: CISF

Marital Status: Married

Socio-economic Status: Lower

Locality: rural

Referred By: Department of Psychiatry

Informant: Wife

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “tention hoti hai ki parievar kese chlega”

“ek jagha duty thi toh waha pe ek officer ne gakat ilzzam lgae maine unse behas krli toh mko
suspen kr diya aur legal case kr diya.

“dimag kam nhi krta h chize smj nhi aatai hai”

“loan kese chukauga job chli jaegi toh”

“raste se nikalta hu toh esa lagta hai ki log meko dekh rahe hai aur mere he bare mia bate kar
rahe hai’

“mai raste mai chlta hu toh log meko dekh ke side hatt jate hai”

“neend nhi aatai hai rt ko”

Informant: “akele akele rethe hai”

“jab ghusse aati hai tab mujhe bhi aur baccho ko bhi mar dete hai”

“duty se bar bar chutti lete hai”

“rat ko neend nhi aati hai”

“inko lagta hai sab inko dekh rahe hai”

“inka sir dukjte retha hai”

HISTORY OF PRESENT ILLNESS (HOPI):

A 35-year-old male patient came to the outpatient department (OPD) accompanied by his
wife. According to the information provided, a few months ago, the patient had an argument
with an officer after being accused of stealing clothes, which the patient denied. As a result of
the confrontation with the officer and his wife, the patient was suspended from his job, and a
case was filed against him.

Since then, the patient has been constantly worrying about how he will manage to pay off his
debts and support his family. This persistent worry has led to significant sleep disturbances.
He has become increasingly paranoid, believing that when he goes out, people are talking
about him, staring at him, and moving aside to discuss him. This has caused him to prefer
isolation, and he now spends much of his time alone.

The patient has also become aggressive, often taking out his frustrations on his wife and
children by physically abusing them when he becomes angry. His wife, who provided the
information, mentioned that he is frequently anxious and withdrawn. He has started talking to
himself, and both his sleep and appetite have been adversely affected. He avoids social
interactions and seems to experience sudden mood swings, sometimes laughing without
reason and then abruptly bursting into tears.

The patient also believes that there is someone inside him, compelling him to do things.
These experiences have further contributed to his disturbed state of mind.

Onset: Sudden

Course: Progressive
Progress of illness: deteriorating

Precipitating Factors: The onset of the current problems can be traced back to the argument
with the officer and the subsequent suspension and legal case filed against the patient.

Predisposing Factors: Environmental Factors: The stress from financial instability, fear of
legal consequences, and societal judgment may have contributed to the onset of his
symptoms.

Personal Factors: The patient’s overall mental resilience may have been compromised by the
stress of providing for his family and managing debts.

Perpetuating Factors: Home Environment: The patient’s aggressive behavior and isolation
likely strain his relationships at home, creating a lack of supportive relationships.

Work Environment: Loss of stable income and ongoing legal issues contribute to his anxiety
and depression.

Social Environment: The patient’s perception that others are talking about him and moving
aside when he passes may reinforce his paranoia and desire to withdraw from social
interactions.

Coping Strategies: The patient’s tendency to ruminate and talk to himself exacerbates his
mental health condition, preventing recovery.

Protective Factors: Social Support: Although limited, the presence of his wife, who is
concerned enough to accompany him to the OPD, might offer some protective support if
engaged effectively.

Potential for Treatment: The patient is seeking help, which indicates an opportunity for
intervention and treatment.

Negative History: no history suggestive of schizophrenia

No history suggestive of tactile hallucination.

PAST MEDICAL HISTORY: No significant past medical history

PAST PSYCHIATRIC HISTORY: There is no detailed past psychiatric history mentioned

FAMILY HISTORY: The patient’s father uses tobacco and has diabetes. Additionally, the
patient’s nephew (his brother's son) suffered from mental health issues, which ultimately led
to his death. This family history may suggest a genetic predisposition to mental health
problems. The father's health conditions and habits might also contribute to a stressful home
environment, potentially influencing the patient's current mental state.

PERSONAL HISTORY:

Birth and Early Development: the patient was born in full term with normal delivery with
birth weight 2kg. birth cry was present. The patient developmental milestone was achieved
on time.

Childhood History: the patient had a difficult childhood as there were limited resources
available.

Education and Schooling History: the patient has completed is BA and was a below
average student.

Occupation History: the patient works in CISF

Marital History: The patient is married and has 2 kids

Sexual History: the patient sexual life is active.

Substance Use History: Patient has occasionally consumed Tabaco

Legal Case: there is a current legal case going on.

 PRE-MORBID PERSONALITY:

Social Relations:

The patient try’s and avoid social situations and relations.

Intellectual Activities, Hobbies and Use of Leisure time: the patient has not reported any
hobbies

Pre-dominant Mood of patient: worried

Character:

 Attitude towards Self: Has not describe his self

 Attitude to work or responsibility: careless
 Interpersonal relationships: avoids relationship
 Moral and religious attitudes and standards: positive attitude towards religious
activity.

Fantasy life:

Not reported

Habits: the patient has disturbed sleeping patterns and his eating habits are normal

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: The patient general appearance was typical. And
attitude towards the examiner was cooperative.

Psycho-Motor Activity: The patient shows signs of increased psycho-motor activity,

particularly when agitated. He may be pacing or fidgeting, and his aggression towards his
wife and children indicates heightened arousal during these moments.

Speech: The patient’s speech may be disorganized or pressured at times, especially when
talking to himself. There could be rapid shifts in tone and content, reflecting his fluctuating
emotional state.

Mood and Affect: The patient’s mood is predominantly anxious and depressed, with
episodes of irritability. His affect is labile, as he experiences sudden shifts from laughter to
crying, indicating emotional instability.

Thought:
  Stream: The flow of thoughts may be erratic, with the patient displaying a tendency
to ruminate on his worries and perceived threats.
 Form: His thoughts may be disorganized, with possible tangential or circumstantial
thinking.
 Possession: The patient experiences delusions of control, believing that someone is
inside him, influencing his actions.
 Content: The content of his thoughts is dominated by paranoia, delusions, and
worries about his financial situation and social reputation. He believes people are
talking about him and moving aside when he passes by.

Perception: The patient may experience hallucinations, possibly auditory, as he believes

someone is inside him commanding him to do things. His perception is likely distorted by his
delusional beliefs.

Cognition: The patient’s cognitive functions, such as attention, memory, and orientation,
may be impaired due to his disturbed mental state. He may have difficulty concentrating and
making decisions.

Judgment: The patient’s judgment is impaired, as evidenced by his inability to control his
aggression and his belief in delusions. His behaviour suggests poor decision-making and a
lack of insight into the consequences of his actions.

Insight: The patient has poor insight into his condition, as he does not recognize the
abnormality of his thoughts and behaviours. He attributes his experiences to external factors,
such as people talking about him or an external presence controlling him

IMPRESSION: F22 Delusional Disorder, F41.1 Anxiety Disorder Unspecified, F33. 0

Major Depression Disorder (MDD), F43.1 Post Traumatic Stress Disorder, F21 Schizotypal
Personality Disorder, F60. 0 Avoidant Personality Disorder
 PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
1-Rorschach Ink Blot Test

2-Millens Clinical Multiaxial Inventory

Clinical Observation and test behaviour:

He presented an overall neat and well-groomed appearance. He demonstrated awareness of

his surroundings and maintained proper eye contact. His attitude towards the examiner was

reasonably cooperative, and a rapport was successfully established. His speech exhibited

audible intensity with a normal speed.

Rorschach Ink Blot Test

Structural Summary:

Location Features Determinants Contents Approach

Zf= 11 Single H=0 I = W.W.

ZSum= 32 M= 0 (H) = 0 II = D.D.
ZEst = 34.5 FM = 0 Hd = 1 III = D.D.

m=0 (Hd)= 0 IV = W.

W=6 FC = 0 Hx = 0 V = W.

D = 11 CF = 1 A= 7 VI = D.W.
Dd = 2 C= 0 Ad = 2 VII = D.D.
S= 0 Cn= 1 (Ad)= 0 VIII = D.Dd.D.
DQ FC’= 0 An= 3 IX = D.W.
+=7 C’F= 0 Art= 0 X = D.Dd. D
O=8 C’= 1 Ay= 0
V=4 FT= 0 Bt= 1
V/+ = 0 TF= 0 Cg= 0
T= 0 Cl= 0
FV= 0 Ex= 0
VF= 0 Fd= 0
Blends: 0 V= 0 Fi= 0 Special scores
FY= 0 Ge= 0 LVL1 LVL2
YF= 0 Hh= 0 DV= 0 1
Y= 0 Ls= 0 INC= 1 0
Fr= 0 Na= 0 DR= 0 0
Rf= 0 Sc= 1 FAB= 0 0
FD= 0 Sx= 0 ALOG= 0 0
F= 15 Xy= 0 CON= 0 0
Id= 3 Raw Sum 6= 2
(A) = 0 Wgtd= 4
(2) = 9
AB= 0 PHR= 1
AG= 0 GHR = 0
Form Quality COP= 0 MOR = 0
FQx MQual W + D= 17 CP= 1 PER= 0
n=1 n=0 n=1 PSV= 2
o=6 o=0 o=5
u=9 u=0 u=8
-=3 -=0 -=3

Ratios, percentages and Derivations

R = 19 L = 3.75
EB = 0:1 EA = 1 EBPer = 0 FC: CF + C = 0:1 AG = 0
eb = 0:0 es = 0 D=1 Pure C = 0 a: p = 0
Adj es = 1 Adj D = 0 SumC’: WsumC= 1:1 Human Cont. =1
P=1
FM = 0 SUMT=0 WSUMC=1 Afr =0.58 Pure H =0
m=0 SUMY=0 SUMC’=1 S=0 2AB+(ART+Ay) =0
Blends: R =0:19 ISOLATED R=0.05
CP = 1 Zd= -2.5

a: p = 0:0 Sum6 = 2 XA% = 0.78 Zf= 11 3r + (2)/R = 0.47

Ma: Mp = 0:0 Lv2 = 1 WDA% = 0.76 W:D: Dd = 6:11:2 Fr + rF = 0
Mor = 0 Wsum6 = 4 X-%= 0.15 W:M = 6:0 SumV = 0
M- = 0 X+% = 0.31 DQ+ = 7 MOR = 0
Xu% = 0.47 DQv= 4 H: (H) + Hd + (Hd) = 0.1

PTI = 0 DEPI = 2 CDI = 4 S-CON= 3 HVI= No OBS= No

Interpretation

Findings it suggests that the personality organization of the person is somewhat less mature
than might be expected. This tends to create a vulnerability for problems in coping with the
requirements of everyday living. Such difficulties usually are manifest in the interpersonal
sphere and can easily contribute to problems in control when they occur.
Scores also suggests more limited available resources.

Findings also suggests that the stress tolerance of the person is lower than usual and typical
capacities for control may be less sturdy than is customary.

Scores suggest that the individual seems as willing as most others with their particular coping
style (or age in the instance of children) to process and become involved with emotionally
toned stimuli. Generally, this is not a significant finding but, if the person tends to have
persistent difficulties with the modulation or control of emotion it may indicate a naive lack
of
awareness concerning those problems. Usually, when emotional stimuli are processed some
response or exchange is required.

Findings signifies that the individual often denies the presence of irritating or un- pleasant
emotion or emotional stimulation by substituting an inappropriately positive emotion or
emotional value to the situation. This is a hysteroidlike process that disregards or violates
reality. Typically, people who use this form of defence feel very uncomfortable about their
ability to deal adequately with negative feelings and often have problems in modulating their
own affective displays. Consequently, they are prone to bend reality to avoid dealing with
perceived or anticipated harshness in the environment. This form of defensiveness is often
quite transparent and people who use it frequently tend to find themselves being judged by
others as being emotionally superficial.

Scores indicates that the person is striving to accomplish more than may be reasonable in
light of current functional capacities. If this tendency occurs in everyday behaviours, the
probability of failure to achieve objectives is increased, and the consequent impact of those
failures can often include the experience of frustration.

Findings suggests that, at times, the person has some difficulty shifting attention.

Findings suggest that patient has mediational dysfunction.

Scores suggests that if an avoidant style does exist, it is probable that the person tends to
react quickly to reduce the irritations created by the intrusions of peripheral thoughts.

it suggests that the individual tends to be much more involved with himself or herself than
are most others. If one or more reflection responses ap- pear in the record, it indicates that the

narcissistic-like feature is strongly embedded in the psychology of the person and is

sustaining favorable judgments concerning the self in relation to others. If there are no
reflection answers in the record, it signals an unusually strong concern with the self, which
easily leads to a neglect of the external world.
Finding indicates that the person is probably less socially mature than might be expected.
This is the type of individual who is limited in social skills and is disposed to experience
frequent difficulties when interacting with the environment, especially the interpersonal
sphere. Relations with others are likely to be more superficial and less easily sustained.
People such as this are often regarded by others as being distant, inept, or helpless in their
dealings with people, and they tend to be less sensitive to the needs and interests of others.

Scores also suggest that it usually suggests that the person tends to acknowledge and/or
express his or her needs for closeness in ways that are dissimilar to those of most people. It
does not mean that the person fails to have such needs. Instead, it indicates that the individual
is more conservative than might be anticipated in close interpersonal situations, especially
those involving tactile exchange. People who are T-less tend to be overly concerned with
personal space, and much more cautious about creating or maintaining close emotional ties
with others.

Test Impression

The findings suggest that the individual has a less mature personality organization, making
them vulnerable to everyday coping challenges, especially in interpersonal contexts. They
have limited resources and lower stress tolerance, leading to less sturdy control capacities.
While they are as willing as others with a similar coping style to engage with emotionally
toned stimuli, they may lack awareness in controlling emotions, often substituting negative
feelings with inappropriately positive ones, creating an impression of emotional
superficiality. The individual tends to strive beyond their functional capacities, increasing
frustration from frequent failures. They may have difficulty shifting attention and exhibit
mediational dysfunction. If an avoidant style is present, they react quickly to peripheral
irritations. They are highly self-involved, potentially neglecting external realities, and display
lower social maturity with limited social skills, often perceived as distant or inept. Their need
for closeness is expressed conservatively, with an overemphasis on personal space, leading to
caution in forming close emotional ties.
 Millen’s Clinical Multiaxial Inventory
SCORE
CATEGORY PROFILE OF BR SCORE DIAGNOSTIC SCALES
RAW BR
X 123 75 DISCLOSURE
MODIFYING Y 10 47 DESIRABILITY
INDICES
Z 20 76 DEBASEMENT

1 16 89 SCHIZOID

2A 17 91 AVOIDANT
2B 13 78 DEPRESSIVE
3 12 83 DEPENDENT
CLINICAL 4 9 16 HISTORIONIC
PERSONALITY 5 11 52 NARCISSISTIC
PATTERNS 6A 5 60 ANTISOCIAL
6B 10 69 SADISTIC
7 15 54 COMPULSIVE
8A 10 68 NEGATIVISTIC
8B 9 73 MASOCHISTIC

S 20 92 SCHIZOTYPAL
SEVERE
PERSONALITY C 12 75 BORDERLINE
PATHOLOGY P 19 85 PARANOID

A 16 103 ANXIETY

H 12 74 SOMATOFORM
N 8 69 BIPOLAR:MANIC
CLINICAL
D 11 75 DYSTHYMIA
SYNDROMES
B 7 75 ALCOHOL DEPENDENCE
T 2 40 DRUG DEPENDENCE
R 19 95 POST-TRAUMATIC STRESS

SS 18 85 THOUGHT DISORDER
SEVERE
CC 18 99 MAJOR DEPRESSION
CLINICAL
SYNDROMES PP 7 100 DELUSIONAL DISORDER

0 10 20 30 40 50 60 70 80 90 100
Profile Severity:
On the basis of the test data, it may be reasonable to assume that the patient is experiencing a
moderately severe mental disorder; further professional study may be advisable to assess the
need for ongoing clinical care.
Possible Diagnosis:
Client appears to fit the following Axis II classifications best: Schizotypal Personality
Disorder, Avoidant Personality Disorder with Depressive Personality Features and Paranoid
Personality Disorder.
Axis I clinical syndromes are suggested by the client's MCMI-III profile in the areas of
Anxiety, delusion, thought process and Major Depression and prone towards having
problems related to alcohol and Dysthymia.

Response Tendencies:
The patient has engaged in adequate disclosure, and the protocol is valid for interpretation.
However, it is cautioned that the consistency score is questionable indicating an over-
reporting or random responding of symptoms.

Interpretation

AXIS-I

The high- scoring patient has symptoms associated with physiological arousal. They would
be described as anxious, apprehensive, restless, and unable to relax, edgy, jittery, and
indecisive. Symptoms can include complaints of insomnia, muscular tightness, headaches,
nausea, cold sweats, undue perspiration, clammy hands, and palpitations. Phobias
may or may not be present. High scores may meet the DSM- IV criteria for
Generalized Anxiety Disorder or other anxiety- related disorders.

Patients scoring in the clinically significant ranges on Scale PP are likely to be diagnosed
with some type of paranoid disorder. They have persecutory or grandiose delusions and
maintain a hostile, hypervigilant, and suspicious wariness for anticipated or perceived threats.
They may also become belligerent and have irrational ideas of reference, thought
influence, or thought control. The scale is thought to be a symptomatic expression of an
underlying paranoid personality.

High- scoring patients may be unable to manage their day- to- day activities. They are
severely depressed, with feelings of worthlessness and vegetative
symptoms of depression (e.g., loss of energy, appetite, and weight;
sleep disturbances; fatigue; loss of sexual drive or desire). Suicidal ideation may be present.
Their underlying personality style is likely to be
of the emotionally detached type, especially dependent or depressed.

High- scoring patients are reporting symptoms that might include distressing and intrusive
thoughts, flashbacks, startle responses, emotional numbing, problems in anger management,
difficulties with sleep or with concentration, and psychological distress upon exposure to
people, places, or events that resemble some aspect of the traumatic event. A clinical
evaluation is needed to determine which symptoms are present and the degree of functional
impairment.

Patients with elevated scores are admitting to thinking that is disorganized, confused,
fragmented, or bizarre. Hallucinations and / or delusions may also be present. Their
behaviour is often withdrawn or seclusive. They often show inappropriate affect and appear
confused and regressed.

Patients shows traits of behaviourally apathetic, socially withdrawn, feel guilty, pessimistic,
discouraged, and preoccupied with feelings of personal inadequacy. They have low self-
esteem and utter self- deprecatory statements, feel worthless, and are persistently sad. They
have many self- doubts and show introverted behaviour. If physical symptoms appear, they
can include problems in concentration, poor appetite, and suicidal ideation.

Patient shows trait of history of problematic drinking or personality traits frequently seen in
alcoholics.

AXIS-II

High- scoring patients present as emotionally bland with flat affect or with an anxious
wariness. Generally, they are socially detached and have a pervasive discomfort in social
relationships. Accordingly, they remain on the periphery of society with few or no personal
attachments. Thought processes may be tangential, irrelevant, or confused.
They appear self- absorbed in their own thoughts. It is believed that they are prone to
develop Schizophrenia if sufficiently stressed.

Patients with significant elevation of 2A are hypersensitive to rejection, both fearing and
anticipating negative evaluations. Thus, they manifest a wary detachment (avoidance).
Because they are quite sensitive to signs of disapproval, they tend to withdraw from or
reduce social contacts. Others are able to maintain a good social appearance despite them
underlying fears. Their essential conflict is a strong desire to relate socially and an equally
strong expectation of disapproval, depreciation, and rejection. They may use fantasy as their
main defence. They are at risk for developing social phobias.

The patient shows trait of gloomy, pessimistic, overly serious, quiet, passive, and
preoccupied with negative events. These patients often feel quite inadequate and have low
self- esteem. They tend to unnecessarily brood and worry, and, though they are usually
responsible and conscientious, they also are self- reproaching and self- critical regardless of
their level of accomplishment. They seem to be “down” all the time and are quite hard to
please. They tend to find fault in even the most joyous experience. They feel it is futile to try
to make improvements in themselves, in their relationships, or in any significant aspect of
their lives because their incessant pessimism leads them toward a defeatist outlook. Their
depressive demeanour often makes others around them feel guilty, since these patients are
overly dependent on others for support and acceptance. They have difficulty expressing
anger and aggression and perhaps displace it onto themselves. Interestingly, while their mood
is often one of dejection and while their cognitions are dominated by negative thoughts, they
often do not consider themselves depressed.

The patient shows trait of vigilantly mistrustful and often perceive that people are trying to
control or influence them in malevolent ways. They are characteristically abrasive, irritable,
hostile, and irascible, and may also become belligerent if provoked. Their thinking is rigid
and they can be argumentative. They may present with delusions of grandeur or persecution
and / or ideas of reference. They use projection as their main defence.

POSSIBLE DSM-V MULTIAXIAL DIAGNOSIS

The major complaints and behaviours of the patient parallel the following Axis II diagnoses,
listed in order of their clinical significance and salience.

Axis I: Clinical Syndromes:

297.1 Delusional Disorder
300 Anxiety Disorder Unspecified
296.3 Major Depression Disorder (MDD)
309.81 Post Traumatic Stress Disorder
Thought Disorder

Axis II: Personality Disorders:

301.22 Schizotypal Personality Disorder
301.82 Avoidant Personality Disorder
 DIAGNOSTIC FORMULATION:

Points in Favour: Presence of paranoid delusions and auditory hallucinations.

Disorganized thought processes and erratic mood swings.

Family history of mental health issues.

Recent stressor (accusation and job suspension) leading to a deterioration in mental health.

Points in Against: Lack of detailed past psychiatric history to establish a pattern.

Absence of other contributing medical conditions, which could rule out organic causes.

PROGNOSIS: The prognosis is guarded, given the severity of the symptoms, the patient’s
lack of insight, and the chronic nature of the stressors. However, with appropriate treatment
and support, there may be potential for improvement.

DIFFERENTIAL DIAGNOSIS:

Schizophrenia: Due to the presence of delusions, hallucinations, and disorganized thought

processes.

Major Depressive Disorder with Psychotic Features: Considering the mood disturbances and
possible psychotic symptoms.

Bipolar Disorder: If mood swings between manic and depressive states are identified.
Substance-Induced Psychotic Disorder: If there is any history of substance abuse contributing
to the symptoms.

MANAGEMENT PLAN:

Immediate Safety: Address the safety of the patient and his family by potentially considering
hospitalization if there is a risk of harm.

Pharmacotherapy: Initiate antipsychotic medication to manage psychotic symptoms. Mood

stabilizers or antidepressants may be considered if mood symptoms are prominent.

Psychotherapy: Cognitive-behavioural therapy (CBT) could be introduced once the patient

stabilizes to help address delusional thoughts and improve insight.

Family Support: Engage the family in therapy to ensure they understand the patient’s
condition and how to support him effectively.

Social Support: Explore social services for financial assistance and community support to
reduce stressors.

Follow-Up: Regular psychiatric follow-up to monitor symptoms, medication adherence, and

any potential side effects.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288
 Sri Aurobindo Medical College and University, Indore, M.P.
Department of Clinical Psychology

CASE HISTORY No.: 3

OPD No.: 15313596

SOCIO-DEMOGRAPHIC DETAILS:

Name: M C

Age: 10

Gender: Male

Education: 4TH

Occupation: Student

Marital Status: N/A

Socio-economic Status: Upper

Locality: Urban/Sub-urban/rural

Referred By: Department of Psychiatry

Informant: Uncle

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “mko bht ghusse aata hai”

“mujhe chize share krna nhi psnd hai”

“jab mmy papa ladhte hai toh ghusse aata hai”

Informant: “ye kisi se bhi sharing nhi krta hai”

“bht ghusse aata h isko”

“ghusse mai Dusre baccho marta hai”

“agar zidd puri na ho toh chize tod fod krne lgta hai”

“eyes blink krte retha hai”

“concentration nhi lagta”

“isko ADHD diagnose hue tha”

HISTORY OF PRESENT ILLNESS (HOPI):

A 10-year-old male patient was brought to the outpatient department (OPD) by his uncle. His
medical history indicates that he was born after a full-term pregnancy via caesarean section
and was overweight at birth. From an early age, he has struggled with digestive problems. As
he grew older, he was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), a
condition that affects his ability to concentrate and control impulses.

The boy exhibits significant behavioural challenges. He is particularly reluctant to share

anything, whether it be toys, belongings, or other items, with anyone, including his close
family members. This reluctance is not merely a preference but is accompanied by intense
emotional reactions. When people do not comply with his wishes or listen to him, he
becomes extremely angry. His anger manifests in physical outbursts, such as throwing
objects, breaking things, and even physically assaulting other children.
The boy’s anger and frustration are not limited to interactions with peers. He also experiences
heightened emotional distress when witnessing conflicts between his parents. His parents’
arguments seem to exacerbate his Behavioural issues, further fuelling his anger and feelings
of instability.

A significant turning point in his life occurred when his father was transferred to Italy for
work. The boy did not adapt well to this change, as he had a strong preference for staying in
India. The move to a new country, away from the familiar environment of India, added to his
stress and contributed to his ongoing difficulties with managing emotions and behaviour.

In summary, this 10-year-old boy presents with a complex array of Behavioural and
emotional issues, rooted in both his medical condition (ADHD) and his challenging life
circumstances, including his difficulty adapting to change, particularly his father's relocation
to Italy.

Onset: early in life

Course: chronic and consistent

Progress of illness: static

Precipitating Factors: the relocation to Italy

Predisposing Factors: Family dynamics: The patient becomes upset when his parents argue,
indicating that family conflict may predispose him to heightened emotional distress.

Environmental changes: The move to Italy could have triggered increased stress, given the
significant change in culture and environment.

Perpetuating Factors: Lack of coping mechanisms: The patient does not appear to have
developed effective ways to manage his emotions, particularly anger.

Unresolved family conflicts: Parental arguments and possibly lack of stable support within
the family environment may continue to perpetuate the patient’s Behavioural issues.

Social challenges: Difficulty in sharing and interacting with peers may isolate the patient,
further exacerbating his behaviour.
Protective Factors: Supportive family members: The presence of an uncle who brought the
patient to the OPD indicates that there is some level of family support, which may help in
managing the patient’s condition.

Diagnosis and awareness: Early diagnosis of ADHD might allow for targeted interventions to
help manage the patient’s behaviour.

Negative History:- no history suggestive of underlying psychiatric disorder.

-no history suggestive of autism spectrum disorder.

PAST MEDICAL HISTORY: Born full-term via C-section, overweight at birth.

Ongoing digestive problems since birth.

did not receive his mother's milk after birth

PAST PSYCHIATRIC HISTORY: Diagnosed with ADHD. No other psychiatric history

provided.

FAMILY HISTORY: no significant family history.

PERSONAL HISTORY:
Birth and Early Development: he was born after a full-term pregnancy via caesarean
section and was overweight at birth. From an early age, he has struggled with digestive
problems and didn’t received mother milk after birth.

Childhood History: he was diagnosed with ADHD

Education and Schooling History: he is currently in class 4th and is an above average
student.

Occupation History: he is a student.

PRE-MORBID PERSONALITY:

Social Relations: The patient has difficulty interacting with family members, particularly in
sharing with his sister. He becomes upset when his parents argue, which suggests a sensitivity
to family dynamics.

Intellectual Activities, Hobbies and Use of Leisure time: he likes to play with his toys.

Pre-dominant Mood of patient: The patient appears to have a predominantly irritable and
angry mood, especially when faced with situations that do not go his way or when he is not
listened to. He also shows signs of distress during family conflicts.

Character:

 Attitude towards Self: The patient may exhibit low self-esteem, as his difficulty with
emotional regulation and aggressive behaviour could indicate underlying frustration
or dissatisfaction with himself.
 Attitude to work or responsibility: he may struggle with focus and completing
tasks.
 Interpersonal relationships: The patient has significant difficulties in interpersonal
relationships, characterized by anger, aggression, and reluctance to share or engage
positively with others.
 Moral and religious attitudes and standards: not reported
Fantasy life: not reported

Habits: irregular sleeping patterns and his diet is normal

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: the patient came into to the opd well dressed and was
very cooperative with the examiner.

Psycho-Motor Activity: The patient demonstrates hyperactive behavior, including physical

aggression such as hitting other children, throwing objects, and breaking things. His psycho-
motor activity appears to be elevated, consistent with his diagnosis of ADHD.

Speech: patient speech was stuttered.

Mood and Affect: Mood: Predominantly irritable and easily angered, especially in situations
where his needs or desires are not met.

Affect: Likely labile, with quick shifts to anger and frustration, possibly incongruent with the
situation at hand.

Thought:

 Stream: Likely disorganized or pressured, given the ADHD diagnosis, with possible
difficulty maintaining a coherent stream of thoughts.
 Form: loose associations or tangential thinking, especially under stress or when
frustrated.
 Possession: No evidence of thought insertion, withdrawal, or broadcasting. Thought
possession appears intact.
 Content: The content of his thoughts likely revolves around his immediate needs,
frustrations, and possibly feelings of injustice or anger when things do not go his way.
Perception: No hallucinations or perceptual disturbances have been reported. The patient’s
perception of reality appears intact.

Cognition: The patient has normal intellectual abilities but may have impaired attention,
focus, and executive functioning due to ADHD.
Judgment: impaired, especially in situations that trigger anger. The patient’s decision-
making may be impulsive and not fully consider consequences.

Insight: The patient likely has limited insight into his condition and the impact of his
behaviour on others. He may not fully understand why his actions are problematic.

IMPRESSION: Attention Deficit Hyperactivity Disorder F90. 9

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment difficulty in concentration

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
1. Malin’s Intelligence Scale for Indian Children (MISIC)
2. Vineland Social Maturity Scale (VSMS)

Medical:

 Vision- Normal
 Speech- stuttering

Behaviour Observation during Testing- o General Appearance: - His

general appearance was well kempt and tidy.
o Language and communication: - Speech was stutter.
o Comprehension of test instructions: - Could comprehend test
instructions easily.
o Attention concentration: Attention was easily sustained for
long period of time.

Test Description:
 Verbal Intelligence is the ability to analyse information and solve
problems using language-based reasoning. Language-based reasoning
may involve reading, writing, listening to words, conversing, thinking,
and from classroom learning to social communication.
Verbal Tests IQ
Information 85
Comprehension 93
Arithmetic 115
Similarities 85
Digit Span 130
Verbal IQ 102

Nonverbal intelligence is the ability to analyse information and solve

problems using visual or hands or reasoning.
Nonverbal Tests IQ
Picture Completion 85
Block Design 109
Object Assembly 61
Coding 85
Mazes 91
Performance IQ 86

On MISIC Intellectual Functioning, Tanvi performed up to an IQ of 54

(mild) On the verbal scale he performed up to IQ 76 (borderline) and
on the performance scale, she scored up to 65(mild) on full scale
intelligence quotient assessment.
Test Findings:
Verbal Intelligence Quotient: 102
Performance Intelligence Quotient: 86
Full Scale Intelligence Quotient: 94
Test Interpretation: on the basis of the test, it can be concluded that
patient has average level of intelligence.

Test Findings:
 Vineland Social Maturity Scale Social Age: 120 months
Social Quotient: that is 100 which means he has average level of social adaptive
functioning.

Pattern Analysis of Vineland Social Maturity Scale (VSMS)

S.no Social Social Age Social Quotient Interpretation

Areas/Domain (Months)
1. Self Help 88 73 borderline level
General

2. Self Help 116 96 average level

Eating

3. Self Help 156 130 Superior

Dressing

4. Self-Direction 168 140 genius

5. Occupation 144 120 Above Average

level
6. Communication 124 103 average level

Locomotion 116 96 average level

7.

8. Socialization 168 140 genius

Test Impression

On the basis of brief clinical history, developmental history, clinical observation and
psychological test findings it can be concluded that patient has average level of
intelligence at present according to Malin’s Intelligence Scale for Indian Children and
average level of socio adaptive functioning at present.

DIAGNOSTIC FORMULATION:
Points in Favour: Early onset of symptoms.

Diagnosis of ADHD, which is consistent with the observed hyperactivity and impulsivity.

Environmental stressors (family conflict, relocation) that likely exacerbate symptoms.

History of digestive issues and lack of breastfeeding, which might have impacted early
development.

Points in Against: No mention of other neurodevelopmental or psychological evaluations,

which might rule out co-morbid conditions such as oppositional defiant disorder (ODD) or
conduct disorder.

Limited information on school performance and peer interactions outside the immediate
context provided.

PROGNOSIS: The prognosis depends on early intervention, family support, and the
implementation of appropriate Behavioural and pharmacological therapies. With
comprehensive management, there is potential for improvement, but without it, the risk of
ongoing Behavioural issues remains high.

DIFFERENTIAL DIAGNOSIS:

ADHD (Primary diagnosis)

Oppositional Defiant Disorder (ODD): Given the aggressive behaviour, a co-morbid

diagnosis of ODD could be considered.

Conduct Disorder: If behaviours escalate in severity or involve more serious violations of

social norms.
Anxiety Disorder: The patient's response to stressors like parental conflict and relocation
might also be indicative of underlying anxiety.

MANAGEMENT PLAN:

Behavioural Therapy: Focused on anger management, social skills training, and emotional
regulation.

Parental Training: To equip parents with strategies to manage the child’s behaviour at home
and reduce conflict.

Pharmacotherapy: Consideration of stimulant or non-stimulant medications for ADHD.

Educational Support: Coordination with the school to provide a supportive learning

environment.

Psychoeducation: For the patient and family to improve understanding of ADHD and
associated behaviors.

Support for Environmental Stressors: Addressing family conflict and exploring ways to ease
the patient’s adjustment to environmental changes like relocation.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288
 Sri Aurobindo Medical College and University, Indore, M.P.
Department of Clinical Psychology

CASE HISTORY No.: 5

OPD No.: 14743236

SOCIO-DEMOGRAPHIC DETAILS:

Name: P.D

Age: 17yr

Gender: Female

Education: 9th

Occupation: Student

Marital Status: N/A

Socio-economic Status: Lower Class

Locality: Sub-urban

Referred By: Self

Informant: Mother

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: Patients denies any problem.

Informant: According to the informant, the patient experiences significant memory lapses
and struggles with basic daily tasks unless specifically prompted. For instance, she neglects
bathing unless reminded to do so, and despite attempting to study, she cannot retain
information. She even forgets simple details like the duration of her menstrual cycle or what
she eats for breakfast. Moreover, her attention seems to be primarily drawn to negative
aspects of her life.

HISTORY OF PRESENT ILLNESS (HOPI):

A young patient arrived at the outpatient department (OPD) accompanied by her mother. The
patient, who is the second child in the family with one older and one younger sibling, faced
complications during birth. Her cry after birth was delayed, and she was born prematurely
with low birth weight, necessitating an 11/2-month hospitalization post-birth. Unfortunately,
she couldn't be breastfed.

Despite these early challenges, her developmental milestones, such as walking and talking,
were achieved within normal ranges. However, her mother expressed concerns about her
memory, noting that she struggles to recall everyday details like meals, the current day, or
even the timing of her menstrual cycle. This forgetfulness extends to basic hygiene practices,
particularly during menstruation. Without guidance, she doesn't know when to change
sanitary products or even when to bathe.

In essence, the patient's upbringing was marked by early health hurdles and ongoing
cognitive difficulties, leading to struggles with memory and self-care, especially during
menstruation.

Onset: Insidious

Course: Continuous
Progress of illness: Fluctuating

Precipitating Factors: N/A

Predisposing Factors: N/A

Perpetuating Factors: Lack of support at home

Protective Factors: N/A

Negative History:

 No history suggestive of significant Head Injury.

 No history suggestive of harmful use of any psychoactive substance.
 No history suggestive of intense fear of specific object or situation.
 No history suggestive of intrusive repetitive thoughts, images, impulses or any
repetitive behaviour.
 No history suggestive of perfectionism that interferes with task completion and
intrusion of insistent and unwelcome thoughts and impulses.

PAST MEDICAL HISTORY:

PD was born prematurely with a low birth weight and experienced a delayed birth cry.
Shortly after birth, PD was admitted to the hospital for a period of 1.5 months. Additionally,
she did not receive breast milk. Despite these challenges, PD's motor development has
progressed normally.

PAST PSYCHIATRIC HISTORY: no psychiatric illness

FAMILY HISTORY:

PD's parents had an arranged marriage and did not disclose any medical history. PD has one
younger brother who is currently attending school, while her other brother is not currently
employed. There are no reported illnesses in the family. PD's father is employed, and her
mother is a homemaker.
PERSONAL HISTORY:

Birth and Early Development: PD was born prematurely with a low birth weight and
experienced a delayed birth cry. Shortly after birth, PD was admitted to the hospital for a
period of 1.5 months. Additionally, she did not receive breast milk. Despite these challenges,
PD's motor development has progressed normally.

Childhood History: her childhood was little difficult as she has lack of support from family

Education and Schooling History: she struggles in her studies

Occupation History: she stays home

Menstrual History: started at the age of 13

PRE-MORBID PERSONALITY:

Social Relations: have a strained or dependent relationship with family members, given the
lack of support at home.

Intellectual Activities, Hobbies and Use of Leisure time: minimal engagement in

intellectual activities or hobbies, possibly due to cognitive challenges.

Pre-dominant Mood of patient: subdued

Character:
  Attitude towards Self: passive attitude towards self
 Attitude to work or responsibility: struggles with responsibility
 Interpersonal relationships: dependent
 Moral and religious attitudes and standards: she is a religious person

Fantasy life:

Not reported

Habits:

Her eating and sleeping habits are normal

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: her appearance was typical and showed a positive
attitude.

Psycho-Motor Activity: slow or lethargic.

Speech: struggle with complex expression due to cognitive issues.

Mood and Affect: neutral and subdued

Thought:

 Stream: coherent, but may be slow or limited in complexity.

 Form: simple, concrete thinking
 Possession: intact.
 Content: normal, no intrusive thoughts or obsessions reported.

Perception: normal, with no hallucinations or perceptual disturbances reported.

Cognition: Memory issues are evident, especially in day-to-day recall and self-care.
Judgment: impaired, particularly in self-care and daily functioning.

Insight: limited, particularly in understanding her condition and needs.

IMPRESSION: Moderate Intellectual Impairment

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
1- Binet Kamat Test (BKT)

Developmental History-

o Milestones:
 Motor- normal
 Speech- Developed
Medical:

 Vision- Normal
 Speech- developed
.

Behavior Observation during Testing-

The patient presented with a general appearance. Furthermore, the patient seemed
disoriented, lacking awareness of time and date. It was also challenging to capture and sustain
the patient's attention for the necessary duration. Conducting the test was quite challenging,
as the patient required multiple prompts and instructions during the assessment.

 Binet Kamat Test

• . Mental Age: 92 months
• I.Q.: 48 moderate level of intellectual impairment

Disability: 75%

Test Impression: On the basis of brief clinical history, developmental history,

clinical observation and psychological test findings it can be concluded that patient
has moderate level of intellectual impairment at present.

DIAGNOSTIC FORMULATION:

Points in Favour: Premature birth and low birth weight.

Delayed cry and prolonged hospitalization.

Memory and self-care difficulties.

Lack of support at home.

Points in Against: No significant head injury

No substance use

no psychiatric history.

PROGNOSIS: guarded given the fluctuating progress of illness and lack of support at home.
Early intervention and support could improve outcomes.

DIFFERENTIAL DIAGNOSIS:
Mild Cognitive Impairment due to Perinatal Complications.

Developmental Disorder Not Otherwise Specified (NOS).

Mild Intellectual Disability (considering normal developmental milestones but current

cognitive challenges)

MANAGEMENT PLAN:

Medical: Comprehensive cognitive assessment to determine specific deficits.

Possible referral to a neurologist for further evaluation.

Psychological: Cognitive-behavioural therapy (CBT) to improve memory and self-care skills.

Psychoeducation for family members to enhance support at home.

Social: Engagement with community services to provide social and educational support.

Supportive: Regular follow-ups to monitor progress and adjust the management plan
accordingly.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288
 Sri Aurobindo Medical College and University, Indore, M.P. Department of Clinical
Psychology

CASE HISTORY No.: 6

OPD No.: 14765932

SOCIO-DEMOGRAPHIC DETAILS:

Name: A B

Age: 27yr

Gender: Male

Education: 7th

Occupation: N/A

Marital Status: Not Married

Socio-economic Status: Middle Class

Locality: Sub-urban
Referred By: Self

Informant: Sister

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient:

1. “Chakar aate hai humesha”

2. “Shaadi nhi Hori hai uski tension hai”
3. “Meri ungli kamzor hai sahi se chize nhi pakad pata

Informant:

According to the informant, the patient is unable to comprehend anything. He cannot go

anywhere on his own, cannot be trusted with money, and is unable to take care of his
belongings or himself. He is also very unhygienic. In his childhood, he was struck on the
head with a rolling pin by his mother, after which he began experiencing dizziness. He still
feels dizzy whenever he is under stress.

HISTORY OF PRESENT ILLNESS (HOPI):

Onset: 8-10 years

Course: Continuous

Progress of illness: Static

Precipitating Factors: was hit by mother with rolling pin.

Predisposing Factors: N/A

Perpetuating Factors: lack of supportive relationship and lack of friendship

Protective Factors: N/A

Negative History:

 No history suggestive of harmful use of any psychoactive substance.

 No history suggestive of intense fear of specific object or situation.
 No history suggestive of intrusive repetitive thoughts, images, impulses or any
repetitive behaviour.

PAST MEDICAL HISTORY: There is no medical history

PAST PSYCHIATRIC HISTORY: There is no psychiatric history

FAMILY HISTORY:

AB's parents had an arranged marriage. AB is the second-born child, with one older and one
younger sibling. Her younger sister exhibits similar symptoms. There is no history of medical
or mental illness among family members. The father is employed, and the mother is a
homemaker.
PERSONAL HISTORY:

Birth and Early Development: the patient was born in 7 months with 2 kg weight. Birth cry
was present and his developmental milestone was typical

Childhood History: his childhood was normal though he had limited resources.

Education and Schooling History: the patient studied till class 7th as he couldn’t
comprehend.

Occupation History: he is not working right now

PRE-MORBID PERSONALITY:

Social Relations: his relationship with others were normal

Intellectual Activities, Hobbies and Use of Leisure time: patients likes to use his mobile

Pre-dominant Mood of patient: carefree

Character:

• Attitude towards Self: didn’t describe

• Attitude to work or responsibility: was always careless when comes to
responsibility
• Interpersonal relationships: were normal
• Moral and religious attitudes and standards: he is a religious person

Fantasy life: not significant

Habits:

Eating and sleeping patterns are normal

 MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: hie general appearance was normal and attitude
towards the clinician was positive.

Psycho-Motor Activity: restlessness and agitation.

Speech: his speech was normal

Mood and Affect: The patient exhibits a mood that might be described as anxious or
distressed, particularly with concerns about not getting married. Affect may be flat or
restricted due to ongoing stress and dizziness.

Thought:

• Stream: The thought process appears to be slow or disorganized, possibly

due to cognitive difficulties.
• Form: There may be evidence of impaired organization or coherence in
thought, especially given the issues with comprehension and decision-making.

• Possession: The patient might have delusions related to his physical

symptoms or stress
• Content: Thoughts may be dominated by worries about marriage and personal
abilities

Perception: There is no evidence of hallucinations or other perceptual disturbances

mentioned.

Cognition: Cognitive abilities are impaired, particularly in comprehension and daily

functioning. Memory and executive functions may also be compromised.

Judgment: Judgment is likely impaired given the patient's inability to manage money,
personal hygiene, and daily tasks. This is compounded by a lack of supportive relationships.
Insight: Insight into his condition may be limited, especially if the patient cannot fully
comprehend or acknowledge the impact of his symptoms on his daily life.

IMPRESSION: Moderate Intellectual Impairment

PSYCHOLOGICAL ASSESMENT:
Rationale for Psychological Assessment as patient couldn’t comprehend things easily

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
2- Binet Kamat Test (BKT)
3-
Developmental History-

o Milestones:
 Motor- normal
 Speech- not developed
Medical:

 Vision- Normal
 Speech- not developed
Family History- younger sister exhibits same symptoms..

Behavior Observation during Testing-

The patient presented with a general appearance. Furthermore, the patient seemed
disoriented, lacking awareness of time and date. It was also challenging to capture and sustain
the patient's attention for the necessary duration. Conducting the test was quite challenging,
as the patient required multiple prompts and instructions during the assessment.

 Binet Kamat Test

• . Mental Age: 90 months
• I.Q.: 47 moderate level of intellectual impairment

Disability: 75%
 Test Impression: On the basis of brief clinical history, developmental history,
clinical observation and psychological test findings it can be concluded that patient
has moderate level of intellectual impairment at present.

DIAGNOSTIC FORMULATION:

Points in Favour: Chronic dizziness and cognitive impairment following a head injury.

Cognitive and functional impairments observed in daily activities.

No history of substance abuse or psychiatric disorders.

Points in Against: The static nature of symptoms and the lack of clear psychiatric or
neurological diagnoses may require further investigation.

Similar symptoms in the younger sister suggest a possible genetic or environmental factor.

PROGNOSIS: The prognosis might be guarded given the static nature of the symptoms and
the lack of significant improvement. Supportive interventions and management of stress
could potentially improve quality of life but may not significantly alter the static course of the
condition.

DIFFERENTIAL DIAGNOSIS:

Post-Traumatic Cognitive Disorder: Due to head trauma.

Chronic Dizziness Syndrome: Related to stress or head injury.

Neurodegenerative Disorder: Considering similar symptoms in the family.

Functional Neurological Disorder: Given the lack of identifiable organic pathology.

MANAGEMENT PLAN:

Medical Evaluation: Further neurological evaluation to assess any possible damage or

changes in brain function.

Cognitive Rehabilitation: Therapy to improve cognitive function and daily living skills.

Stress Management: Techniques such as relaxation exercises, counseling, and support groups.

Social Support: Engage family members or caregivers to provide support and improve daily
functioning.

Psychological Support: Counseling or therapy to address the emotional impact of symptoms

and improve coping strategies.
Reported by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.: 7

OPD No.: 14831330

SOCIO-DEMOGRAPHIC DETAILS:

Name: DA

Age: 5 years

Gender: Male

Education: Nursery

Occupation: Student

Marital Status: N/A

Socio-economic Status: Moderate Socio-Economic

Locality: Urban

Referred By: Department of Audio and Speech

Informant: Parents

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS

Informant:

According to the informant, the patient is unable to speak but can understand things. He is
capable of saying only two-letter words. He began walking at the age of one year. At 1.5
months old, he was admitted to the NICU because his weight had dropped from 3 kg to 1.5
kg and he was unresponsive. At that time, he kept his eyes closed and did not move at all.

HISTORY OF PRESENT ILLNESS (HOPI):

The patient arrived at the outpatient department (OPD) with his parents. He was born at full
term via normal delivery, weighing 3 kg. He was breastfed for the first month of life, but
feeding was discontinued afterward.

At 1.5 months old, he was admitted to the neonatal intensive care unit (NICU) due to a lack
of responsiveness and closed eyes, and his weight had dropped to 1.5 kg. Additionally,
whenever he drank water, he would cough. He has not developed speech; although he
attempts to speak, he is unable to do so.

Onset: Insidious

Course: Continues

Progress of illness: Improving

Precipitating Factors: N/A

Predisposing Factors: N/A

Perpetuating Factors: N/A

Protective Factors: N/A

Negative History:

- no history suggestive of brain injury

-no history suggestive of organic cause

PAST MEDICAL HISTORY: At 1.5 months old, he was admitted to the neonatal intensive
care unit (NICU) due to a lack of responsiveness and closed eyes, and his weight had dropped
to 1.5 kg.

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: The patient's mother experienced a miscarriage prior to his birth.
During his infancy, she was unable to produce milk. Additionally, the patient's aunt did not
begin speaking until she was 4 years old.

PERSONAL HISTORY:

Birth and Early Development He was born at full term via normal delivery, weighing 3 kg.
He was breastfed for the first month of life, but feeding was discontinued afterward.
At 1.5 months old, he was admitted to the neonatal intensive care unit (NICU) due to a lack
of responsiveness and closed eyes, and his weight had dropped to 1.5 kg. Additionally,
whenever he drank water, he would cough. He has not developed speech; although he
attempts to speak, he is unable to do so.

Childhood History: he had a normal childhood with supportive family.

Education and Schooling History: he studies in nursery

Occupation History: student

PRE-MORBID PERSONALITY:

Social Relations: his social relation is normal

Intellectual Activities, Hobbies and Use of Leisure time: he likes to play with his toys

Pre-dominant Mood of patient: cheerful

Character:

 Attitude towards Self: positive

 Attitude to work or responsibility: not significant
 Interpersonal relationships: are positive
 Moral and religious attitudes and standards: not significant

Fantasy life: not significant

Habits:

His sleeping and eating habits are normal

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: he came in with general appearance and behaviour
toward the clinician was very cooperative

Psycho-Motor Activity: influenced by the patient's developmental status and difficulty in

communication.

Speech: The patient has not developed speech and attempts to speak but is unable to do so
Mood and Affect: influenced by the challenges with speech and communication.

Thought:

 Stream: N/A
 Form: N/A
 Possession: N/A
 Content: N/A

Perception: Not Reported

Cognition: The patient shows developmental delays in speech, which may impact overall
cognitive functioning.

Judgment: N/A

Insight: N/A

IMPRESSION: Average level of Socio Adaptive Functioning

PSYCHOLOGICAL ASSESMENT:
Rationale for Psychological Assessment was referred for IQ assessment by department of
audio and speech

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
4- Vineland Social Maturity Scale (VSMS)

Developmental History-

Milestones:
 Motor- Normal
 Speech- Not Developed Medical:
 Vision- Normal
 Speech- not developed
  Family History- the patients aunt started speaking by the age of 4. The patient’s mother

had a previous pregnancy, resulting in the birth of a daughter who tragically passed away

shortly after birth due to complications related to the amniotic fluid

Behavior Observation during Testing-

The overall appearance of the patient seemed typical. However, he exhibited challenges in
maintaining eye contact. The patient displayed impatience and was repeating whatever his
parents had to say. Establishing rapport with the patient was easy.

Test Findings:
 Vineland Social Maturity Scale Social Age: 54.6 months
Social Quotient: that is 91 which means he has average level of social adaptive
functioning.

Pattern Analysis of Vineland Social Maturity Scale (VSMS)

S.no Social Social Age Social Quotient Interpretation

Areas/Domain (Months)
7. Self Help 52 87 Below average
General level
8. Self Help 32 53 mild level
Eating
9. Self Help 56 93 Average level
Dressing
10. Self-Direction N/A N/A N/A
11. Occupation 60 100 Average level
12. Communication 64 107 average level

Locomotion 40 67 Mild level

7.

8. Socialization 60 100 average level

  Test Interpretation: 91 social quotient that indicates that the patient has
average level of social adaptive functioning

DIAGNOSTIC FORMULATION:

Points in Favour:

Full-term birth, normal delivery, and initial breastfeeding.

Insidious onset with continuous course but improving progress.

No history suggestive of brain injury or organic cause

Points in Against:

Significant developmental delays, particularly in speech.

Past NICU admission due to lack of responsiveness and weight drop

PROGNOSIS: The prognosis appears cautiously optimistic given the improving condition.
Continued monitoring and supportive interventions may help in further development.

DIFFERENTIAL DIAGNOSIS:

Developmental language disorder.

Motor speech disorders.

Neurological conditions affecting early development.

MANAGEMENT PLAN:

Developmental Support: Regular speech and language therapy to address communication

delays.

Monitoring and Assessment: Regular follow-ups to monitor developmental progress and

adjust interventions as needed.
Family Support: Providing guidance and support to the family to manage developmental
challenges and enhance caregiving.

Nutritional Support: Ensuring proper nutrition to support overall growth and development.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.: 8

OPD No.: 14804201

SOCIO-DEMOGRAPHIC DETAILS:

Name: N V

Age: 1O

Gender: Female

Education: 3rd

Occupation: Student

Marital Status: N/A

Socio-economic Status: lower middle

Locality: Sub-urban

Referred By: Paediatric

Informant: Family

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “kuch smj nhi aata”

Informant: “thk se bolti nhi hai “

“dimag ka santulan thk nhi hai”

“kisi ki bat smj nhi pati hai”

“kam karne ki koshish karti hai par kar nhi pati hai”

“developmental delay hai”

HISTORY OF PRESENT ILLNESS (HOPI):

The 10-year-old patient visited the outpatient department with her mother. According to the
information provided, she was born at full term with a birth weight of 3 kg. Her
developmental milestones were notably delayed: she achieved head control at 2 years old,
began sitting unsupported at 4 years, and started speaking at 6 years. She began walking at 7
years and could walk upstairs by 8 years. She learned to eat independently at 5 years and
began asking for food at 7 years. Despite these milestones, she struggles with walking,
comprehension, and speech. Additionally, there is a family history of a grandfather who had a
ruptured eardrum.
Onset: The onset of developmental delays seems to have been gradual, with milestones such
as head control, sitting, walking, and speaking emerging significantly later than typical
developmental timelines

Course: Continuous

Progress of illness: improving

Precipitating Factors: There are no specific events or triggers mentioned that led to the
current developmental challenges.

Predisposing Factors: The patient was born full-term with a low birth weight of 3 kg. She
also had early feeding difficulties, as she was not breastfed and had a low weight drop post-
birth. Environmental and genetic factors might play a role, but no specific climatic or
infectious factors are mentioned.

Perpetuating Factors: Lack of Supportive Relationships: There may be limited supportive

relationships that could be contributing to the patient’s ongoing challenges.

Developmental Challenges: Difficulty with understanding and speaking clearly might be

maintained by limited intervention or support in overcoming these developmental delays.

Protective Factors: Family Support: The patient is brought to the outpatient department by
her mother, indicating family engagement in seeking medical attention.

Gradual Milestone Achievement: Despite delays, the patient has achieved various
developmental milestones, suggesting some degree of progression and adaptation.

Negative History:-no history suggestive of brain injury

-no history suggestive of psychiatric illness.

PAST MEDICAL HISTORY: Born full-term with a birth weight of 3 kg.

Admitted to NICU at 1.5 months old due to lack of responsiveness and weight drop.

Early feeding difficulties, as she was not breastfed.

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: Grandfather had a ruptured eardrum.

PERSONAL HISTORY:

Birth and Early Development: The 10-year-old patient visited the outpatient department
with her mother. According to the information provided, she was born at full term with a
birth weight of 3 kg. Her developmental milestones were notably delayed: she achieved head
control at 2 years old, began sitting unsupported at 4 years, and started speaking at 6 years.
She began walking at 7 years and could walk upstairs by 8 years. She learned to eat
independently at 5 years and began asking for food at 7 years. Despite these milestones, she
struggles with walking, comprehension, and speech.

Childhood History: her childhood was difficult has she had developmental delay.

Education and Schooling History: she didn’t go to school

Occupation History: not significant

PRE-MORBID PERSONALITY:

Social Relations: she has normal and positive relationship

Intellectual Activities, Hobbies and Use of Leisure time: like to plays with toys

Pre-dominant Mood of patient: difficulties with communication and understanding might

contribute to frustration or stress.

Character:
  Attitude towards Self: low self-esteem
 Attitude to work or responsibility: N/A
 Interpersonal relationships: normal and positive
 Moral and religious attitudes and standards: N/A

Habits:

Normal eating and sleeping habits

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: her general appearance was normal

Psycho-Motor Activity: The patient has difficulty with walking and other motor skills,
which might affect her overall psycho-motor activity.

Speech: The patient struggles with speaking clearly, which impacts her ability to
communicate effectively.

Mood and Affect: influenced by her developmental challenges.

Thought:

 Stream: affected by developmental delays, possibly leading to difficulties in thinking

processes.
 Form: not specified
 Possession: not specified
 Content: not specified

Perception: no abnormalities

Cognition: The patient’s cognitive abilities are impacted, with significant delays in
developmental milestones such as walking, speaking, and understanding.

Judgment: affected due to cognitive delays and difficulty with communication.

Insight: not described

IMPRESSION: Moderate level of socio adaptive functioning.

PSYCHOLOGICAL ASSESMENT:
Rationale for Psychological Assessment the patient developmental milestone are delayed
 Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
5- Vineland Social Maturity Scale (VSMS)

Behavior Observation during Testing-

The overall appearance of the patient seemed typical. However, she exhibited challenges in
maintaining eye contact and was not easily responsive to attempts to capture her attention.
The patient displayed impatience and prevented her
father from speaking. Establishing rapport with the patient proved to be challenging.

Test Findings:
 Vineland Social Maturity Scale Social Age: 56 months
Social Quotient: that is 47 which means she has moderate level of social adaptive
functioning.

Pattern Analysis of Vineland Social Maturity Scale (VSMS)

S.no Social Social Age Social Quotient Interpretation
Areas/Domain (Months)
13. Self Help 52 43 moderate level
General

14. Self Help 32 27 Severe level

Eating

15. Self Help 60 50 Mild level

Dressing

16. Self-Direction N/A N/A N/A

 17. Occupation 60 50 Mild level

18. Communication 40 33 severe level

Locomotion 52 43 Moderate level

7.

8. Socialization 60 50 mild level

 Test Interpretation: 47 social quotient that indicates that the patient has

moderate level of social adaptive functioning

DIAGNOSTIC FORMULATION:

Points in Favour: Delayed developmental milestones in motor skills and speech.

Gradual progression in achieving milestones.

No significant head injury or organic cause found.

Points in Against: No clear precipitating events or additional causes identified.

Limited information on family dynamics and social interactions.

PROGNOSIS: The prognosis may be variable, depending on continued support,

intervention, and management of developmental delays. Improvement is possible, but
ongoing challenges are likely.

DIFFERENTIAL DIAGNOSIS:

Developmental Coordination Disorder: Given the motor skill delays.

Specific Language Impairment: Considering the speech difficulties.

Autism Spectrum Disorder: Might be considered if additional behavioral or communication
challenges are present.

Global Developmental Delay: Due to delays across multiple areas.

MANAGEMENT PLAN:

Intervention: Early intervention programs focusing on speech therapy, occupational therapy,

and physical therapy to address developmental delays.

Support: Engage in family counselling and support services to improve home environment
and support systems.

Education: Special educational support to address learning needs and social skills
development.

Follow-Up: Regular monitoring and adjustment of the intervention plan based on progress
and emerging needs.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288
Sri Aurobindo Medical College and University, Indore, M.P.
Department of Clinical Psychology

CASE HISTORY No.: 9

OPD No.: 14826672

SOCIO-DEMOGRAPHIC DETAILS:

Name: H M
Age: 24

Gender: Male

Education: 10th

Occupation: Student

Marital Status: N/A

Socio-economic Status: Middle

Locality: Sub-urban

Referred By: Department of Psychiatry

Informant: Father

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient:

“mujhe nhi pta mai yaha kyu aaya hai”

Informant:

“kamzor dimag hai”

“ziddi karta hai”

“kabhi nahata hai kabhi nahi”

HISTORY OF PRESENT ILLNESS (HOPI):

The 10-year-old male patient, born full term with a birth weight of 3 kg and no
developmental delays, exhibits difficulties in comprehension and personal hygiene. He
struggles with understanding instructions and managing daily tasks.

Onset: Insidious
Course: continuous

Progress of illness: static

Precipitating Factors: No specific event or trigger mentioned that led to the onset of the
symptoms.

Predisposing Factors: There are no specific environmental, climatic, or health-related factors

detailed that predispose the patient to the current condition.

Perpetuating Factors: lack of support

Protective Factors: N/A

Negative History:-no history significant of psychiatric illness

PAST MEDICAL HISTORY: N/A

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: N/A

PERSONAL HISTORY:
Birth and Early Development: born full term with a birth weight of 3 kg and no
developmental delays

Childhood History: childhood was difficult as there was lack of support from family.

Education and Schooling History: didn’t go to school

Occupation History: N/A

PRE-MORBID PERSONALITY:

Social Relations: normal family relation

Intellectual Activities, Hobbies and Use of Leisure time: not reported

Pre-dominant Mood of patient: not significant

Character:

 Attitude towards Self: not reported

 Attitude to work or responsibility: careless
 Interpersonal relationships: normal
 Moral and religious attitudes and standards: not reported

Habits:

Normal eating and sleeping habits

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: typical general appearance and was not cooperative
with the clinician.

Psycho-Motor Activity: normal

Speech: normal

Mood and Affect: not impacted

Thought:

 Stream: disrupted due to comprehension difficulties.

 Form: not specified
 Possession: not informed

 Content: Struggles with understanding instructions and daily tasks.

Perception: not significant

Cognition: Exhibits difficulties in comprehension and managing daily tasks.

Judgment: impaired due to struggles with understanding and managing daily

responsibilities.

Insight: not significant

IMPRESSION: Moderate Intellectual Impairment

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment he has difficulty comprehending

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
Binet Kamat Test

Behavior Observation during Testing-

The patient appeared well-groomed and exhibited orientation regarding the time, date, year,
and their current location. However, they faced challenges in grasping the contents of the test.
Nevertheless, their attention could be easily captured and sustained for the necessary duration
as required.
  Binet Kamat Test
• . Mental Age: 84 months
• I.Q.: 44 moderate level of intellectual impairment

Disability: 75%

Test Impression: On the basis of brief clinical history, developmental history,

clinical observation and psychological test findings it can be concluded that patient
has moderate level of intellectual impairment at present.

DIAGNOSTIC FORMULATION:

Points in Favour: Full-term birth with no initial developmental delays.

Persistent issues with understanding and hygiene.

Points in Against: No specific precipitating events or detailed information on other factors

affecting the condition.

PROGNOSIS: depends on the underlying cause of the difficulties and the availability of
supportive interventions.

DIFFERENTIAL DIAGNOSIS: Potential cognitive or developmental disorders.

Possible impact of environmental or familial factors

MANAGEMENT PLAN:

Intervention: Tailored educational support, counselling, and development of coping

strategies.

Support: Engagement with family to improve support systems and address any environmental
factors.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma
M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.: 10

OPD No.: 14167377

SOCIO-DEMOGRAPHIC DETAILS:

Name: A B

Age: 35

Gender: Female
Education: N/A

Occupation: N/A

Marital Status: N/A

Socio-economic Status: Lower

Locality: rural

Referred By: Dhar District Hospital

Informant: Sister-in-law

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “patients speech was not develop”

Informant:

“marne lag jati hai”

“khud se kuch nhi karti”

“khud se nahati bhi nhi hai”

“kuch samaj nhi aata hai”

“bilkul bhi hygenic nhi hai”

“3-4 din mai nihalan padhta hai”

HISTORY OF PRESENT ILLNESS (HOPI):

A 35-year-old woman arrived at the OPD accompanied by her sister-in-law. It was reported
that the patient is unable to understand anything and struggles with personal hygiene. She
requires assistance with bathing every 3-4 days and is incapable of managing tasks on her
own.

Onset: The symptoms appear to have developed over time, though the exact onset is not
specified.

Course: continuous

Progress of illness: static

Precipitating Factors: No specific event or trigger has been identified that led to the onset of
the current problem.

Predisposing Factors: The patient's overall health and age may be contributing factors, but
specific environmental or dietary factors have not been noted.

Perpetuating Factors: The patient’s inability to comprehend things, lack of personal hygiene,
and dependence on others for basic tasks, along with a possible lack of supportive
relationships, are likely perpetuating the condition.

Protective Factors: The presence of a caring sister-in-law who accompanies the patient and
helps with bathing every 3-4 days serves as a protective factor.

Negative History:- no history suggestive of psychiatric illness.

PAST MEDICAL HISTORY: Not reported

PAST PSYCHIATRIC HISTORY: not reported

FAMILY HISTORY: no significant family history was reported

PERSONAL HISTORY:

Birth and Early Development: the patient was born with full-term delivery with 2 kg
weight. Her birth cry was absent. Her developmental milestone was normal.

Childhood History: she had a difficult childhood as she had limited resources available.

Education and Schooling History: she had no education

Occupation History: not significant

Menstrual History: she started her periods by the age of 15

PRE-MORBID PERSONALITY:

Social Relations: limited social relationships. Her sister-in-law is a key figure in her life,
accompanying her to the OPD and assisting with personal care. There is no mention of other
family, friends, or social interactions.
Intellectual Activities, Hobbies and Use of Leisure time: not significant

Pre-dominant Mood of patient: didn’t describe

Character:

 Attitude towards Self: The patient shows little to no awareness of her own condition
or personal hygiene needs, indicating a passive or dependent attitude toward self-care.
 Attitude to work or responsibility: The patient is unable to work or manage
responsibilities independently.
 Interpersonal relationships: Her sister-in-law is the primary caretaker
 Moral and religious attitudes and standards: not reported

Fantasy life: not significant

Habits:

Normal eating and sleeping habits.

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: she came in with general appearance and she didn’t
respond to anything the clinician said

Psycho-Motor Activity: her dependency suggests reduced psycho-motor activity.

Speech: her speech is not developed

Mood and Affect: her lack of comprehension and self-care could imply a flat and blunted
affect.

Thought:
  Stream: not specified
 Form: disorganised
 Possession: not reported
 Content: inability to comprehend suggests limited and impaired thought content.

Perception: not significant

Cognition: significant cognitive impairments, unable to understand or manage personal care.

Judgment: Severely impaired, as the patient cannot make decisions regarding her hygiene or
daily activities.

Insight: The patient lacks insight into her condition, relying entirely on others for care.

IMPRESSION: Severe Intellectual Impairment

PSYCHOLOGICAL ASSESMENT:
Rationale for Psychological Assessment lack of comprehension and hygiene.

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
1. Binet Kamat Test of Intelligence
(BKT)
 Behaviour Observation during Testing- o General Appearance: - She came with her
sister-in-law. Her general appearance was well kempt and tidy.
Language and communication: - Speech is not developed.
Comprehension of test instructions: - Could not comprehend simple test
instructions properly and was unable to write during the test.

Test Findings:

• Binet Kamat Test of Intelligence (BKT)

• Mental Age: 10 months
• I.Q.: 26 Severe Level of Intellectual Impairment

Disability: 90%

Test Impression: On the basis of brief clinical history, developmental history, clinical
observation and psychological test findings it can be concluded that patient has severe
level of intellectual functioning at present.

DIAGNOSTIC FORMULATION:

Points in Favour: Continuous cognitive impairment, lack of hygiene, dependence on others,

static condition.

Points in Against: No history of psychiatric illness or significant medical conditions, no clear

precipitating factors.

PROGNOSIS: The prognosis may be poor due to the static nature of the condition and the
patient’s dependence on others for care.
DIFFERENTIAL DIAGNOSIS: Major neurocognitive disorder (dementia), intellectual
disability, or other neurodevelopmental disorders.

MANAGEMENT PLAN: Implementation of a supportive care plan involving caregivers.

Possible referral to social services for long-term care support.

Further evaluation to rule out underlying medical or neurological conditions.

Reported by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

 Department of Clinical Psychology

CASE HISTORY No.: 11

OPD No.: 14161188

SOCIO-DEMOGRAPHIC DETAILS:

Name: A K

Age: 11

Gender: Female

Education: N/A

Occupation: N/A

Marital Status: N/A

Socio-economic Status: Lower

Locality: Urban

Referred By: Department of Psychiatry

Informant: Father

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “patient had no idea about why she was brought to the opd”

Informant:

“jhatke aata hai”

“jab jhatke aate h toh pta nhi chlta hai koi batat h tab pta lgta h ki jhatke aate h”

“ek din mai 4-5 br jhatke aate hai”

“last seizure 1 saal ke pehle aaya tha”

“garmi bht zda lagti hai”

HISTORY OF PRESENT ILLNESS (HOPI):

An 11-year-old girl came to the OPD with her mother. According to the information
provided, the patient experiences seizures. During these episodes, she has no memory of what
happened unless others inform her afterward. She used to have seizures 4-5 times a day, but
her last seizure occurred a year ago. Additionally, she is highly sensitive to heat.

Onset: insidious

Course: continuous

Progress of illness: improving

Precipitating Factors: not significant

Predisposing Factors: The patient's sensitivity to heat may be a predisposing factor,

potentially linked to her seizures.

Perpetuating Factors: not reported

Protective Factors: supportive family

Negative History: - no history suggestive of head injury.

-no history suggestive of harmful substance use

PAST MEDICAL HISTORY: The patient has a history of frequent seizures, previously
occurring 4-5 times a day.

PAST PSYCHIATRIC HISTORY: not significant

FAMILY HISTORY: not significant

PERSONAL HISTORY:

Birth and Early Development: the patient was born in 7 months with 1.5 kg weight. Her
developmental milestone was normal

Childhood History: her childhood is difficult due to frequent seizure

Education and Schooling History: she studied till class 1 and then because of seizure she
stopped going to school

Occupation History: not significant

PRE-MORBID PERSONALITY:

Social Relations: her social relation are normal

Intellectual Activities, Hobbies and Use of Leisure time: she likes to play with barbie

Pre-dominant Mood of patient: cheerful

Character:

 Attitude towards Self: not reported

 Attitude to work or responsibility: not significant
 Interpersonal relationships: are good as she has supportive family
 Moral and religious attitudes and standards: not significant

Fantasy life:

Not significant

Habits: her eating and sleeping habits are normal

 MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: The patient appears well-groomed, and her behaviour
during the examination was appropriate

Psycho-Motor Activity: No abnormalities in psychomotor activity have been reported

Speech: normal speech

Mood and Affect: mood and affect were normal

Thought:

 Stream: No abnormalities in the thought stream were noted.

 Form: no abnormalities
 Possession: no abnormalities
 Content: no abnormalities

Perception: There are no reported disturbances in perception.

Cognition: no abnormalities

Judgment: no impairment

Insight: no abnormalities

IMPRESSION: Average Level of Intelligence

PSYCHOLOGICAL ASSESMENT:
Rationale for Psychological Assessment repeated seizure

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
1. Binet Kamat Test of
Intelligence

Behaviour Observation during Testing- o General Appearance: - She came with her
father. Her general appearance was well kempt and tidy.
Language and communication: - Speech.
Comprehension of test instructions: - could comprehend simple test
instructions properly and was able to write during the test.

Test Findings:

• Binet Kamat Test of Intelligence (BKT)

• Mental Age: 8years 3months
• I.Q.: 76 average Level of Intellectual Impairment

Test Impression: On the basis of brief clinical history, developmental history, clinical
observation and psychological test findings it can be concluded that patient has
average level of IQ

DIAGNOSTIC FORMULATION:
Points in Favour: History of multiple daily seizures, now resolved for a year.

No memory of seizures, indicating possible generalized tonic-clonic seizures.

High sensitivity to heat, which may be a contributing factor.

Points in Against: Lack of identified triggers or predisposing factors.

No family history of similar conditions.

Absence of supportive social or environmental factors that could perpetuate the condition

PROGNOSIS: The prognosis appears positive, given the absence of seizures for the past
year. However, ongoing monitoring is advised due to the history of frequent episodes.

DIFFERENTIAL DIAGNOSIS:

Generalized tonic-clonic seizures

Temporal lobe epilepsy

Non-epileptic seizures

MANAGEMENT PLAN:

Regular follow-up to monitor seizure activity.

Possible EEG to assess current brain activity.

Consideration of environmental factors such as heat sensitivity.

Supportive counselling for the patient and family to manage any residual anxiety or concerns
regarding seizures.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288
 Sri Aurobindo Medical College and University, Indore, M.P.
Department of Clinical Psychology

CASE HISTORY No.: 12

OPD No.: 14268772

SOCIO-DEMOGRAPHIC DETAILS:

Name: P T

Age: 3

Gender: Male

Education: N/A

Occupation: N/A

Marital Status: N/A

Socio-economic Status: Middle

Locality: Sub-urban

Referred By: Department of Audio and speech

Informant: Parents

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “patient didn’t report anything”

Informant:

“Developmental milestone delayed”

HISTORY OF PRESENT ILLNESS (HOPI):

A 3-year-old male patient visited the OPD with his family. According to the information
provided, the patient was born at full term, weighing 3 kg. His birth cry was delayed by 4
minutes. He began walking and talking later than expected. He was breastfed for only the
first 5 months.

Onset: since birth

Course: continuous

Progress of illness: static

Precipitating Factors: not significant

Predisposing Factors: Potential prenatal or perinatal factors given the delayed birth cry by 4
minutes.

Limited breastfeeding duration (only up to 5 months)

Perpetuating Factors: Lack of sufficient early nutrition (breastfeeding stopped after 5

months).

Protective Factors: supportive family.

Negative History:- no history suggestive of psychiatric illness.

PAST MEDICAL HISTORY: Delayed birth cry (by 4 minutes).

Early cessation of breastfeeding (after 5 months).

PAST PSYCHIATRIC HISTORY: not significant

FAMILY HISTORY: no family history

PERSONAL HISTORY:

Birth and Early Development: the patient was born at full term, weighing 3 kg. His birth
cry was delayed by 4 minutes. He began walking and talking later than expected. He was
breastfed for only the first 5 months.

Childhood History: difficult childhood as he had developmental delayed

Education and Schooling History: didn’t go to school

Occupation History: not significant

PRE-MORBID PERSONALITY:

Social Relations: he has normal family relation

Intellectual Activities, Hobbies and Use of Leisure time: likes to play with his toys
Pre-dominant Mood of patient: not significant

Character:

 Attitude towards Self: not significant

 Attitude to work or responsibility: not significant
 Interpersonal relationships: are good
 Moral and religious attitudes and standards: not significant

Fantasy life:

Not significant

Habits: normal eating and sleeping habits.

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: he was appropriately dressed.

Psycho-Motor Activity: Normal activity for age, although developmental delays in walking
is present.

Speech: started talking late

Mood and Affect:

Thought:

 Stream: normal
 Form: no abnormalities
 Possession: intact
 Content: age appropriate

Perception: no abnormalities

Cognition: Mild delays noted in motor skills and speech development.

Judgment: N/A
 Insight: N/A

IMPRESSION: Mild socio adaptive Functioning

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment developmental delays

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered

6- Vineland Social Maturity Scale (VSMS)

Behavior Observation during Testing-

o General Appearance: - He came with his family. His general appearance
was normal.
Language and communication: - Speech is not developed.
o Language and communication: -wasn’t able to communicate at all.

Test Findings:
 Vineland Social Maturity Scale Social Age: 22.6 months
 Social Quotient: 63 that is mild which means he has mild level of intellectual disability.
Pattern Analysis of Vineland Social Maturity Scale (VSMS)

S.no Social Social Age Social Quotient Interpretation

Areas/Domain (Months)
19. Self Help 32 89 Below Average
General
20. Self Help Eating 32 89 Below Average

21. Self Help N/A N/A N/A

Dressing
22. Self-Direction N/A N/A N/A

23. Occupation 60 167 Very superior

 24. Communication 28 78 Borderline

7. Locomotion 52 144 Very superior

8. Socialization 68 189 Very superior

Test Impression: On the basis of brief clinical history, developmental history, clinical
observation and psychological test findings it can be concluded that patient is mildly
intellectually disabled.

DIAGNOSTIC FORMULATION:

Points in Favour: Delayed birth cry (by 4 minutes).

Late onset of walking and talking.

Limited breastfeeding (only up to 5 months).

Points in Against: No significant medical, psychiatric, or familial history identified that could
explain the delays.

PROGNOSIS: Prognosis may depend on early intervention and supportive care. Current
status is static with potential for improvement.

DIFFERENTIAL DIAGNOSIS: Developmental delay due to perinatal asphyxia.

Potential mild cerebral palsy (due to delayed birth cry).

Speech and language delay due to early cessation of breastfeeding.

MANAGEMENT PLAN:

Developmental Assessment: Ongoing evaluation of motor and speech milestones.

Early Intervention: Speech therapy, physiotherapy, and occupational therapy as needed.

Family Education: Provide support and guidance on enhancing developmental progress.

Nutritional Support: Monitor diet and ensure adequate nutrition to support development.

Follow-Up: Regular follow-ups to monitor progress and adjust interventions as necessary.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

 Department of Clinical Psychology

CASE HISTORY No.: 13

OPD No.: 14279490

SOCIO-DEMOGRAPHIC DETAILS:

Name: N M

Age: 3.5

Gender: Female

Education: N/A

Occupation: N/A

Marital Status: N/A

Socio-economic Status: Lower

Locality: Sub-urban

Referred By: Self

Informant: Mother

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “patient has no insight”

Informant: “6 months pe peda hui thi 4 month peti mai thi”

“na ke barabar roe thi”

“sas nhi le pari thi”

“operation se hui thi”

HISTORY OF PRESENT ILLNESS (HOPI):

The patient, who is now 3 years old, came into the outpatient department with her mother.
She was born prematurely at 6 months via caesarean section, and her birth cry was not very
noticeable. She spent 4 months in an incubator due to difficulty breathing at birth. Currently,
she has issues with both speech and hearing.

Onset: The patient was born prematurely at 6 months via caesarean section, with difficulty
breathing and a less noticeable birth cry.

Course: The patient spent 4 months in an incubator due to breathing difficulties at birth.
Currently, she has issues with speech and hearing.

Progress of illness: The condition is improving but remains problematic.

Precipitating Factors: Premature birth and immediate breathing issues at birth.

Predisposing Factors: Premature birth and the associated medical complications.

Perpetuating Factors: Lack of speech and hearing development, which may impact overall
developmental progress.

Protective Factors: The ongoing medical care and attention being given to the patient's
condition.

Negative History: -no significant history suggestive of head injury

PAST MEDICAL HISTORY: Premature birth at 6 months via caesarean section, difficulty
breathing at birth, and time spent in an incubator.

PAST PSYCHIATRIC HISTORY: not significant

FAMILY HISTORY: no history reported

PERSONAL HISTORY:

Birth and Early Development: She was born prematurely at 6 months via caesarean section,
and her birth cry was not very noticeable. She spent 4 months in an incubator due to difficulty
breathing at birth. Currently, she has issues with both speech and hearing.

Childhood History: her childhood was difficult as she has problem in speaking and
listening.

Education and Schooling History: she didn’t go to school

Occupation History: not significant

PRE-MORBID PERSONALITY:

Social Relations: The patient is cared for by her mother and has experienced medical
challenges since birth.

Intellectual Activities, Hobbies and Use of Leisure time: At her age, the patient’s
intellectual activities and hobbies are limited due to her developmental challenges.
Pre-dominant Mood of patient: The predominant mood is not specifically mentioned due
to the patient’s young age and communication difficulties.

Character:

 Attitude towards Self: Difficult to assess directly due to limited verbal

communication.
 Attitude to work or responsibility: N/A
 Interpersonal relationships: N/A
 Moral and religious attitudes and standards: N/A

Fantasy life:

N/A

Habits:

Normal eating and sleeping habits

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: she came in with general appearance.

Psycho-Motor Activity: consistent with developmental age and challenges.

Speech: the patient does not speak

Mood and Affect: are not directly assessable due to limited communication skills.

Thought:

 Stream: N/A
 Form: N/A
  Possession: N/A
 Content: N/A

Perception: Not reported

Cognition: Developmental milestones such as speech and hearing are delayed.

Judgment: N/A

Insight: N/A

IMPRESSION: Mild level of Socio Adaptive Functioning

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment she couldn’t hear or speak

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
7- Vineland Social Maturity Scale (VSMS)

Behavior Observation during Testing-

o General Appearance: - she came with her family. Her general appearance
was normal.
Language and communication: - Speech is not developed.
o Language and communication: -wasn’t able to communicate at all.

Test Findings:
 Vineland Social Maturity Scale Social Age: 25.2 months
 Social Quotient: 59 that is mild which means she has mild level of intellectual disability.
Pattern Analysis of Vineland Social Maturity Scale (VSMS)

S.no Social Social Age Social Quotient Interpretation

Areas/Domain (Months)
25. Self Help 32 74 BORDERLINE
General

26. Self Help Eating 32 74 BORDERLINE

27. Self Help 36 84 BELOW

Dressing AVERAGE

28. Self-Direction N/A N/A N/A

29. Occupation 32 74 BORDERLINE

30. Communication N/A N/A N/A

31. Locomotion 40 92 AVERAGE

32. Socialization 21 49 MODERATE

Test Impression: On the basis of brief clinical history, developmental history, clinical
observation and psychological test findings it can be concluded that patient has mild
intellectual disabled.

DIAGNOSTIC FORMULATION:

Points in Favour: Premature birth with breathing difficulties.

Extended time in an incubator.

Present issues with speech and hearing.

Points in Against: no head injury

PROGNOSIS: The prognosis depends on ongoing medical and therapeutic interventions,

with potential for improvement in developmental milestones with appropriate support.

DIFFERENTIAL DIAGNOSIS: Other developmental disorders such as speech and

language disorders, hearing impairments, or cognitive delays could be considered.

MANAGEMENT PLAN:

Continued medical care and monitoring.

Referral to speech and hearing specialists.

Early intervention programs to support developmental milestones.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288
 Sri Aurobindo Medical College and University, Indore, M.P.
Department of Clinical Psychology

CASE HISTORY No.: 14

OPD No.: 14301002

SOCIO-DEMOGRAPHIC DETAILS:

Name: P P

Age: 4

Gender: Male

Education: N/A

Occupation: N/A

Marital Status: N/A

Socio-economic Status: Middle

Locality: Sub-urban

Referred By: Department of ENT

Informant: Family

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “the patient couldn’t speak or hear”

Informant:
“bolta sunta nahi hai”

HISTORY OF PRESENT ILLNESS (HOPI):

A 4-year-old male patient visited the outpatient department with his family. He was born full
term with a weight of 3 kg, and his developmental milestones were normal. However, he does
not speak or hear.

Onset: The condition began during the early stages of development.

Course: continuous

Progress of illness: static

Precipitating Factors: not significant

Predisposing Factors: not significant

Perpetuating Factors: ack of supportive relationships, insufficient social interactions, and

inadequate coping strategies

Protective Factors: N/A

Negative History:-no history suggestive of head injury

PAST MEDICAL HISTORY: not significant

PAST PSYCHIATRIC HISTORY: not reported

FAMILY HISTORY: not significant

PERSONAL HISTORY:

Birth and Early Development: He was born full term with a weight of 3 kg, and his
developmental milestones were normal. However, he does not speak or hear.

Childhood History: his childhood is difficult as he couldn’t hear or speak

Education and Schooling History: didn’t go to school

Occupation History: not significant

PRE-MORBID PERSONALITY:

Social Relations: his social relation are not good as he hasn’t got the supportive relation

Intellectual Activities, Hobbies and Use of Leisure time: not significant

Pre-dominant Mood of patient: N/A

Character:

 Attitude towards Self: N/A

 Attitude to work or responsibility: N/A
 Interpersonal relationships: N/A
 Moral and religious attitudes and standards: N/A

Fantasy life: N/A

Habits:

Normal sleeping and eating habits.

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: the patient came in with typical appearance.

Psycho-Motor Activity: normal

Speech: The patient does not speak or hear.

Mood and Affect: not specified

Thought:

 Stream: N/A
 Form: N/A
 Possession: N/A
 Content: N/A

Perception: No abnormalities

Cognition: Cognitive abilities related to speech and hearing are affected.

Judgment: N/A
 Insight: N/A

IMPRESSION: Average Level of Socio Adaptive Functioning

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment the patient couldn’t hear or speak

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
8- Vineland Social Maturity Scale (VSMS)
9- Seguin Form Board Test (SFBT)

Behavior Observation during Testing-

o General Appearance: - He came with his family. His general appearance
was normal.
Language and communication: - Speech and hearing is not developed.

Test Findings:
 Vineland Social Maturity Scale Social Age: 52 months
 Social Quotient: 107 that is average which means he has average level of social adaptive
functioning.
 Pattern Analysis of Vineland Social Maturity Scale (VSMS)
S.no Social Social Age Social Quotient Interpretation
Areas/Domain (Months)
33. Self Help 52 108 Average
General
34. Self Help Eating 32 66 Mild
 35. Self Help 54 112 Average
Dressing
36. Self-Direction N/A N/A N/A

37. Occupation 60 125 Very superior

38. Communication 40 83 Below average

7. Locomotion 52 108 Average

8. Socialization 60 125 Very superior

 Test Impression: On the basis of brief clinical history, developmental history,

clinical observation and psychological test findings it can be concluded that patient
has average level of socio adaptive functions
 Seguin Form Board Test (SFBT

 The test impression was invalid because the patient took more than given time as per
the protocol.

DIAGNOSTIC FORMULATION:

Points in Favour:

Normal developmental milestones

Full-term birth with appropriate weight

Points in Against:

Lack of speech and hearing

PROGNOSIS: The static nature of the condition suggests no significant change in the
patient’s ability to speak or hear is expected.
DIFFERENTIAL DIAGNOSIS: Consider hearing impairment or speech disorder due to
other underlying conditions.

MANAGEMENT PLAN:

Assessment for hearing and speech therapies.

Evaluation for possible underlying causes or contributing factors.

Referral to a specialist for further diagnostic testing and treatment options.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

 Department of Clinical Psychology

CASE HISTORY No.: 15

IPD No.: 946617

SOCIO-DEMOGRAPHIC DETAILS:

Name: P

Age: 15

Gender: Male

Education: 10TH

Occupation: Student

Marital Status: N/A

Socio-economic Status: Middle

Locality: Urban

Referred By: Department of Psychiatry

Informant: Brother

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “mera diamg nhi chlta”

“mai kuch nhi kar pata”

15-16 saal bht hote hai jene ke liye”

“mai marna chatha hu “

“meko kisi kisi ki nhi padi”

Informant: “bht aggressive hai”

“kahi pe bhi marne lg jata hai”

“iski demands puri na kro toh bht zda aggressive ho jata hai”

“bate nhi s,jta hai”

“chote bacche jesa behave krta hai”

“urine and stool control mai nhi hai”

HISTORY OF PRESENT ILLNESS (HOPI):

A 15-year-old patient was brought to the OPD by his brother. He was born full-term and
reached his developmental milestones on time. From an early age, he exhibited aggressive
behaviour, such as biting. In 2015, his parents separated, and although he was an above-
average student, he was frequently forced to study and physically punished. The patient was
stubborn, often making demands, and would throw tantrums if his needs were not met.

His heart rate increases to 170 bpm when he becomes agitated. Last year, his father suffered a
stroke, which traumatized the patient. This trauma was compounded when he overheard his
close aunt speaking negatively about him, which left him shocked. Following these events, he
lost hope, began feeling worthless, and believed he was incapable of doing anything right.
His aggressive behaviour worsened, leading him to physically attack his brother and father.

During a visit to the market with his mother, he lay down on raw cement and covered
himself. When his mother tried to stop him, he responded by throwing stones at her. After his
father's stroke, his academic performance declined drastically, dropping from once scoring
90% to getting only 2-3 marks. On one occasion, after experiencing an upset stomach, his
mother instructed him to clean up in the washroom, but instead, he soiled the entire house and
walked in the mess like a young child might.
The patient has made multiple suicide attempts, which he claims are for attention, but these
attempts have become more frequent. His attention-seeking behaviour is escalating, as he
calls relatives at any time, asking them to visit him because he is "unwell." His demands have
also increased, and when they are not met, he becomes aggressive, often beating his brother.
The patient urine and stool are not in his control. He has undergone treatment for
schizophrenia and got 6-7 ECT

Onset: The onset of the patient's issues began last year following two significant events: his
father's stroke and overhearing his aunt speak negatively about him.

Course: Since these events, the patient has exhibited worsening symptoms, including
increased aggression, declining academic performance, and escalating attention-seeking
behaviors.

Progress of illness: deteriorating

Precipitating Factors: the trauma from his father's stroke and the psychological impact of
hearing his aunt criticize him

Predisposing Factors: Potential predisposing factors include the long-standing stress from his
parents' separation and being subjected to physical punishment and academic pressure from
an early age.

Perpetuating Factors: The ongoing lack of a supportive family environment, particularly the
strained relationships with his parents, as well as his declining academic performance, which
may contribute to his worsening behaviour and mental health.

Protective Factors: There appear to be limited protective factors in his current environment,
given the absence of a supportive family dynamic and the ongoing behavioural and emotional
challenges.

Negative History: - no history suggestive of hallucination

-no history suggestive of head injury.

-no history suggestive of delusions

PAST MEDICAL HISTORY: not reported

PAST PSYCHIATRIC HISTORY: he has undergone treatment for schizophrenia and got
6-7 ECT

FAMILY HISTORY: The family history includes parental separation in 2015 and the
father's stroke last year. The family environment is characterized by a lack of support and
strained relationships.

PERSONAL HISTORY:

Birth and Early Development: He was born full-term and reached his developmental
milestones on time

Childhood History: he had a traumatic childhood as his parents got separated and there was
lack of family support.

Education and Schooling History: he studied till class 10th

Occupation History: not significant

PRE-MORBID PERSONALITY:
Social Relations: The patient had strained relationships within his family, particularly after
his parents' separation in 2015. He has had ongoing conflicts, especially with his brother and
father. His interactions with others, including relatives, have been negatively affected by his
aggressive behaviour and attention-seeking tendencies.

Intellectual Activities, Hobbies and Use of Leisure time: like to watch movies

Pre-dominant Mood of patient: The patient has displayed a mood characterized by

frustration, feelings of worthlessness, and increasing aggression.

Character:

 Attitude towards Self: The patient has developed a negative self-image, believing he
is "good for nothing" and incapable of achieving anything.
 Attitude to work or responsibility: His attitude toward academic responsibilities has
deteriorated, as evidenced by his significant decline in academic performance.
 Interpersonal relationships: The patient struggles with maintaining positive
interpersonal relationships, particularly within his family. His interactions have
become increasingly aggressive and conflictual.
 Moral and religious attitudes and standards: he is very interested in mythologies

Habits:

His eating habits are normal but his sleep is disturbed

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: the patient came in with general appearance first he
was not very cooperative with the examiner later he developed a bond of trust with the
examiner
Psycho-Motor Activity: Increased psycho-motor activity is evident in his aggressive
outbursts, physical altercations, and tantrums.

Speech: normal speech

Mood and Affect: The patient's mood is predominantly aggressive, frustrated, and marked
by feelings of worthlessness. His affect is likely to be labile and reactive, especially in
response to perceived slights or unmet demands.

Thought:

 Stream: Likely pressured and disorganized during episodes of anger.

 Form: Thought processes may be disorganized, particularly when agitated.
 Possession: no abnormalities
 Content: Thoughts of worthlessness, frustration, and aggressive impulses. Suicidal
ideation is present, primarily as a means of seeking attention.

Perception: No perceptual disturbances, such as hallucinations or delusions, have been

reported.

Cognition: There is a significant decline in cognitive functioning, particularly in academic

performance and problem-solving abilities.

Judgment: Impaired judgment is evident in his inability to respond appropriately to

situations, such as his regressive behaviour and aggressive actions.

Insight: The patient appears to have limited insight into his condition, acknowledging his
suicide attempts as attention-seeking but not recognizing the underlying emotional distress

IMPRESSION: Depression F32A

PSYCHOLOGICAL ASSESMENT:
Rationale for Psychological Assessment past psychiatric treatment, sucidal ideation,

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
1-Rorschach Ink Blot Test

2- Minnesota Multiphasic Personality Inventory A- RF

Clinical Observation and test behaviour:

His general appearance was neat and well kempt. Touch with surrounding was present. Eye
contact was maintained properly. Attitude towards the examiner was cooperative. Rapport
was established easily. Motor behaviour was appropriate. His was normal. Thought stream
was normal, but thought content was limited. Attention was easily aroused and managed to be
sustained for the required period. he was well oriented towards time, place, day, date, month
and year. he was able to understand and follow the test instructions which were given by the
examiner
Rorschach Ink Blot Test
Structural Summary:

Location Features Determinants Contents Approach

Zf= 14 Single H=2 I=W

ZSum=44 M= 2 (H) =1 II = D.D
ZEst = 45.5 FM =2 Hd = 3 III = D.D.Dd

m=0 (Hd)=0 IV = Dd.D.D

W=2 FC = 1 Hx = 0 V = W.Dd

D = 13 CF = 0 A= 4 VI =D
Dd = 4 C=0 Ad =2 VII = D
S=0 Cn=0 (Ad)=1 VIII = D.D
DQ FC’=0 An=2 IX = D.Dd
+ = 12 C’F=0 Art=1 X = D.D
O =6 C’=0 Ay=0
V =1 FT=0 BT=0
V/+ =0 TF=0 Cg=0
T=0 CL=0
FV=00 Ex=0
VF=0 Fd=0
Blends: 0 V=0 Fi=0 Special scores
FY=0 Ge=0 LVL1 LVL2
YF=0 Hh=0 DV=0
Y=0 Ls=0 INC= 0 1
Fr=0 Na=0 DR=0
Rf=0 Sc=0 FAB=0
FD=0 Sx=0 ALOG=0
F=14 Xy=0 CON=0
Id=0 Raw Sum 6=1
(A)=1 Wgtd=4
(2)=11
AB= 0 PHR=3
AG=1 GHR =3
Form Quality COP=0 MOR = 0
FQx MQual W + D=15 CP=0 PER=0
N=1 N=0 N=1 PSV=0
o=6 o=1 o=6
u = 10 u=0 u=6
-=2 -=1 -=2
 Ratios, percentages and Derivations

R = 19 L = 2.8
EB = 2:4 EA = 6 EBPer = 0 FC: CF + C = 1:0 AG = 1
eb = 2:0 es = 2 D=4 Pure C = 0 a: p = 3:1
Adj es =4 Adj D =2 SumC’: WsumC =0:0.5 Human Cont. = 6
P=4
FM = 2 SUMC=0 WSUMC=0.5 Afr = 0.46 Pure H = 2
m=0 SUMT=0 SUMC’=0 S=0 2AB+(ART+Ay) =1
SUMY=0 Blends: R =0:19 ISOLATED R=0.10
CP = 0 Zd=1.5

a: p =3:1 Sum6 = 1 XA% = 0.52 Zf= 14 3r + (2)/R = 0,57

Ma: Mp =2:0 Lv2 = 1 WDA% = 0.8 W:D: Dd =2:13:4 Fr + rF = 0
Mor = 0 Wsum6 = 4 X-%= 0.10 W:M = 13:2 SumV = 0
M- = 1 X+% = 0.31 DQ+ = 12 MOR = 0
Xu% = 0.52 DQv= 1 H: (H) + Hd + (Hd) = 2:4

PTI = 2 DEPI = 1 CDI = 2 S-CON= . 1 HVI= 3 OBS= 2

Interpretation
Findings signifies that the person has a sturdier tolerance for stress than do most.

Scores suggest that there are Limited available resources.

Scorings also suggest that the stress is rather modest.

Findings indicates that He has a very marked disposition to simplify complexity and
ambiguity by ignoring or denying its presence. He is probably very inconsistent in his
approach to solving problems or making decisions. This lack of consistency is also likely to
affect the manner by which he handles emotions. At times, they may be over- controlled
while in similar instances they may not be controlled appropriately for the situation

Sores also indicates that if the person tends to have persistent difficulties with the modulation
or control of emotion it may indicate a naive lack of awareness concerning those problems.
Usually, when emotional stimuli are processed some response or exchange is required.
Therefore, people who have difficulties with control often find it more beneficial to avoid
emotional stimuli, thereby reducing demands made on them.

Scores also suggest that the person is striving to accomplish more than may be reasonable in
light of current functional capacities. If this tendency occurs in everyday behaviors, the
probability of failure to achieve objectives is increased, and the consequent impact of those
failures can often include the experience of frustration.

Findings suggest that events of mediational dysfunction occur no more frequently than for
most people.

Scores also indicates that peripheral mental activities being generated by need and/or stress
experiences are interfering with effective mediation, probably by disrupting attention and
concentration and intruding into logical patterns of thought.

Findings also indicates that the patient approach a decision using a style of thinking similar to
the They push feelings aside and tend to delay while thinking through various issues. At old
very influenced by feelings, much like the other times, their approach is more intuitive
extratensive. The lack of consistency in the manner by which ambitents conceptualize and
formulate decisions tends to reduce efficiency. As a result, ambitents are more vulnerable to
errors in judgment, and they are more likely to reverse previous judgments. They seem to
profit less from problem-solving errors than do others and, as a result, often require more
time to reach effective solutions. Being an ambitent does not automatically predispose a
person to adjustment problems, but the inconsistency that characterizes their thinking can
become a liability because it often requires more time and effort to contend with the demands
of everyday life.

Score also suggest that avoidant style does exist, it is probable that the person tends to react
quickly to reduce the irritations created by the intrusions of peripheral thoughts.

Findings also indicates that thinking tends to be marked by faulty judgment or ideational
slippage more often than is common. This does not necessarily reflect a thinking problem, but
does suggest that thinking is less clear than might be expected and some of the
conceptualizations of the individual are less mature or less sophisticated than is typical.

Scores also suggest that the individual tends to be much more involved with himself or
herself than are most others. If one or more reflection responses ap- pear in the record, it
indicates that the narcissistic-like feature is strongly embedded in the psychology of the
person and is sustaining favourable judgments concerning the self in relation to others. If
there are no reflection answers in the record, it signals an unusually strong concern with the
self, which easily leads to a neglect of the external world, high self-regard or estimate of
personal worth but, in some instances, this strong concern with the self may signal a sense of
personal dissatisfaction. When the latter is true, the protocol typically will contain other
evidence of self- degradation and/or problems with social adjustment.

Scores also indicates that some body concern may be present.

Test Findings on MMPI A-RF-3:

SCALE T-SCORE INTERPRETATION

CRIN (Combined Response 120 The protocol is uninterpretable.

Inconsistency)
VRIN - r (Variable Response 120 The protocol is uninterpretable.
Inconsistency)
TRIN -r (True Response Inconsistency) 59
the protocol is interpretable
F-r (Infrequent Responses) 76 Significant emotional distress

L-r (Uncommon Virtues) 67 Under reporting

K-r (Infrequent Somatic Responses) 67

Under reporting
EID (Emotional/Internalizing 50 Better than average level of freedom from
Dysfunction) emotional distress

THD (Thought Dysfunction 57 No concern

Interpretation)

BXD (behavioural/externalizing 35
Dysfunction) N/A

RCD (Demoralization) 55 Average level of morale and life satisfaction

64 Multiple somatic complaints that may include

Somatic Complaints (RC1) head pain, neurological and gastrointestinal
Low Positive Emotions (RC2) 49 Positive emotion and being socially engaged

Cynicism (RC3) 44 is possibly over trusting

Anti-social Behaviour (RC4) 50

Below average level of acting out behaviour

Ideas of persecution (RC6) 58 no concern

Dysfunctional Negative Emotions 43 Below average level of negative emotional
(RC7) experience
Aberrant Experiences (RC8) 58 N/A

Hypomanic Activation (RC9) 29 N/A

Malaise (MLS) 73 Experience poor health, weakness, or fatigue

Gastrointestinal complaints (GIC) 67 Above average level of gastrointestinal

complaints
Head pain complaints (HPC) 51 N/A

Neurological complaints (NUC) 66 Vague neurological complaints

Cognitive Complaints (COG) 61 Diffuse pattern of cognitive difficulties

Helplessness/Hopelessness (HLP) 67 Hopeless and helpless.

44 Below average level of self doubt

Self-Doubt (SFD)
Inefficacy (NFC) 47 N/A

Obsession/compulsion (OCS) 47 No concern

Stress /Worry (stw) 38 N/A

Anxiety(AXY) 59 N/A

Anger proness (ANP) 43 No anger problem

Behaviour-restricting fears(BRF) 57 N/A

Specific fear (SPF) 50 Below than average number of specific fears

Negative school attitude (NSA) 64 Higher than average number of negative school
attitudes
Anti-social attitudes (ASA) 39 N/A
 Conduct problems (CNP) 47 No concerns

Substance abuse (SUB) 42 N/A

Negative peer influence (NPI) 49 N/A

Aggression (AGG) 45 No concern

Family problem (FML) 62 Conflictual family relationship, feeling

unappreciated by his family and lack of
familial support
Interpersonal passivity (IPP) 41 N/A

Social avoidance (SAV) 60 Avoid some social events and situations

Shyness (SHY) 61 Being easily shy embarrassed and feeling

uncomfortable around others

Disaffiliativeness (DSF) 68 Dislike of being around others

Aggressiveness (AGGR) 40 Interpersonally passive and submissive

Psychoticism (PSYC) 57 No concern

Disconstraint (DISC) 42 Low level of behavioural and good impulsive

control, possibly reflecting overly constrained
behaviour.

Negative Emotionality/ Neuroticism 43 N/A

(NEGE)

Introversion/Low Positive 67 Higher than average number of low positive

Emotionality (INTR) emotional experiences.

Interpretation
The psychological assessment provides a mixed picture of the individual's emotional and
mental state. There are conflicting indications regarding emotional distress, with one part of
the report suggesting significant emotional distress, while another suggests the person
experiences a better-than-average level of freedom from emotional difficulties.
Underreporting of emotional issues seems to be a factor in these varying interpretations.
Despite this, the individual generally shows an average level of morale and life satisfaction,
with no major concerns flagged in several areas.
The person reports multiple somatic complaints, particularly head pain, neurological issues,
and gastrointestinal problems. There is an above-average level of gastrointestinal complaints,
along with vague neurological symptoms. These physical complaints are accompanied by
diffuse cognitive difficulties, and the person appears to struggle with feelings of hopelessness
and helplessness. Despite these challenges, the individual exhibits below-average levels of
self-doubt and negative emotional experiences.

Behaviourally, the individual demonstrates low levels of acting-out behaviour and good
impulsive control, which may suggest overly constrained behaviour. There are no significant
concerns related to anger or specific fears, but the person tends to avoid social situations,
feels uncomfortable around others, and is interpersonally passive and submissive. The report
also notes a higher-than-average number of negative school attitudes and low positive
emotional experiences, indicating potential challenges in academic or social settings.

The individual's family and social relationships appear strained, with feelings of being
unappreciated and a lack of familial support being significant concerns. The person dislikes
being around others, is easily shy and embarrassed, and may have a tendency to be over-
trusting in social interactions. Health-wise, the individual experiences poor health, weakness,
and fatigue, yet no major concerns are noted regarding anger, specific fears, or other issues.
Overall, the report paints a picture of someone who is struggling with both physical and
emotional challenges, within a context of strained social and family relationships.
Test Impression
The combined summaries present an individual with a complex and multifaceted
psychological profile. Despite having a stronger-than-average tolerance for stress, the person
appears to be operating with limited resources and may be overextending themselves beyond
their functional capacities. This tendency to strive for more than is reasonable could lead to
increased frustration and the risk of failure. The person has a marked disposition to simplify
complexity and ambiguity, often ignoring or denying these challenges. This leads to
inconsistent problem-solving and emotional regulation, where at times emotions are over-
controlled, and in other situations, they may not be appropriately managed.

The individual also seems to have difficulties with emotional modulation, possibly due to a
naive lack of awareness of these issues. They may avoid emotional stimuli to reduce the
demands placed on them, which could be a coping mechanism. Stress-related mental
activities are likely interfering with their attention, concentration, and logical thinking, further
complicating their decision-making process. The person tends to use an inconsistent and
sometimes faulty judgment in decision-making, leading to inefficiencies and a higher
likelihood of errors. This inconsistency might stem from a deep-seated ambivalence in their
thinking, making them more prone to judgmental errors and slower in reaching effective
solutions.
In terms of emotional and social functioning, the person reports multiple somatic complaints,
such as head pain, neurological issues, and gastrointestinal problems, coupled with cognitive
difficulties and feelings of hopelessness. Despite these challenges, they exhibit low levels of
self-doubt and negative emotional experiences. Behaviourally, they avoid social situations,
feel uncomfortable around others, and demonstrate passive and submissive behaviour. The
individual’s family relationships are strained, with a sense of being unappreciated and lacking
support. They may also have narcissistic-like tendencies, being highly self-involved, which
could lead to neglecting external realities and possibly reflect underlying personal
dissatisfaction.

Health-wise, the individual experiences poor health, weakness, and fatigue, though no
significant concerns about anger or specific fears are noted. The overall picture is of someone
who, while having strengths in coping with stress, faces significant challenges related to
emotional regulation, social interaction, cognitive functioning, and physical health. These
difficulties are exacerbated by strained familial relationships and a tendency to simplify
problems, which may hinder their ability to manage daily life effectively. The individual may
benefit from a more supportive environment and targeted strategies to improve emotional and
cognitive functioning.

DIAGNOSTIC FORMULATION:

Points in Favour: History of aggression and behavioural issues since childhood.

Significant decline in academic performance.

Recent traumatic experiences, including his father’s stroke and familial criticism.

Multiple suicidal attempts with increasing frequency.

Escalating attention-seeking behaviors and demands.

Points in Against: Lack of detailed information on other potential psychiatric symptoms, such
as anxiety or psychosis.

No prior history of psychiatric diagnosis before the onset of current symptoms.

PROGNOSIS: The prognosis is guarded, with the potential for improvement if appropriate
interventions are implemented, including addressing family dynamics, managing aggression,
and improving emotional regulation.

DIFFERENTIAL DIAGNOSIS:

Mood Disorder (e.g., Major Depressive Disorder with features of irritability and aggression)

Conduct Disorder

Oppositional Defiant Disorder

Adjustment Disorder with disturbance of conduct

Trauma-Related Disorder (e.g., PTSD)

MANAGEMENT PLAN:

Immediate Interventions: Assess and manage suicidal risk, potentially involving

hospitalization if necessary.

Behavioural Therapy: Focus on managing aggression, improving impulse control, and

developing healthier coping mechanisms.

Family Therapy: Address family dynamics and provide support to improve communication
and reduce conflict.

Academic Support: Tailor an academic plan that accommodates the patient's current
emotional and cognitive challenges.

Pharmacological Intervention: Consider medication for mood stabilization or to manage

aggressive outbursts, if necessary.

Follow-up: Regular follow-up to monitor progress, adjust treatment, and provide ongoing
support

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma
M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.: 16

IPD No.: 913955

SOCIO-DEMOGRAPHIC DETAILS:

Name: R N

Age: 10

Gender: Male
Education: 4th

Occupation: Student

Marital Status: N/A

Socio-economic Status: Middle

Locality: Urban

Referred By: Department of paediatric

Informant: Father

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “jhatke aate hai”

Informant: “jan ye 2.5 years ka tha tabse isko jhatke aate hai”

“starting mai 10-15 din mai aate hai”

“chize yaad rethi hai jb jhatke aate hai”

“ek time dawaii chutt gyi toh tb jhatke aae the”

“jabse dawaii chl rahi hnjhatke band hai”

HISTORY OF PRESENT ILLNESS (HOPI):

A 10-year-old male patient visited the outpatient department with his parents. He was born
full-term with a birth weight of 2 kg, and a birth cry was present. The parents reported that he
experienced his first seizure at 2.5 years old, with episodes occurring every 10-15 days. The
patient retained memory of the episodes during the seizures. Upon the onset of seizures, his
parents sought medical attention, and treatment was initiated. On one occasion, they forgot to
administer the medication, resulting in another seizure. However, since starting the
medication, his seizures have ceased.

Onset: insidious

Course: Seizures initially occurred every 10-15 days.

Progress of illness: improving- The illness has improved since starting medication, with no
seizures occurring while on treatment.

Precipitating Factors: A specific precipitating factor was missing a dose of the prescribed
medication, which led to a seizure

Predisposing Factors: No specific environmental, health, age, or dietary factors were noted
that predisposed the patient to the seizures.

Perpetuating Factors: The continuation of the illness could be influenced by the adherence
to medication. There is no indication of other perpetuating factors, such as lack of support or
poor coping strategies.

Protective Factors: Adherence to the prescribed medication regimen has been a protective
factor in preventing further seizures.

Negative History: -no history suggestive of head injury

-no history suggestive of any psychiatric illness.

PAST MEDICAL HISTORY: First seizure at 2.5 years old.

Regular seizures every 10-15 days until medication was started.

PAST PSYCHIATRIC HISTORY: not significant

FAMILY HISTORY: no family history

PERSONAL HISTORY:

Birth and Early Development: He was born full-term with a birth weight of 2 kg, and a
birth cry was present.

Childhood History: the patient had a difficult childhood as he suffered from seizure at the
age of 2.5 years

Education and Schooling History: 4th

Occupation History: student

PRE-MORBID PERSONALITY:

Social Relations:

Patient social relation are positive

Intellectual Activities, Hobbies and Use of Leisure time: he likes to play with a ball

Pre-dominant Mood of patient: not specified

Character:

 Attitude towards Self: not specified

 Attitude to work or responsibility: he is careless toward his responsibility’s
 Interpersonal relationships: he has a positive interpersonal relationship
 Moral and religious attitudes and standards: not reported

Habits:

The patient has normal sleeping and eating habits

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: the patient came in with typical general appearance
and attitude towards examiner was cooperative.

Psycho-Motor Activity: normal psychomotor activity

Speech: the patient’s speech was slurred

Mood and Affect: not significant

Thought:

 Stream: no abnormalities
 Form: no abnormalities
 Possession: no abnormalities
 Content: no abnormalities
Perception: N/A

Cognition: Normal

Judgment: N/A

Insight: N/A

IMPRESSION: Mild Intellectual Impairment

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment seizures

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
10- Binet Kamat Test (BKT)
11-
Behavior Observation during Testing-
The patient presented with a general appearance. Furthermore, the patient seemed
disoriented, lacking awareness of time, month, year and date. It was easy to capture and
sustain the patient's attention for the necessary duration. Conducting the test was quite
challenging, as the patient required multiple prompts and instructions during the assessment.

 Binet Kamat Test

• . Mental Age: 78 months
• I.Q.: 65 mild level of intellectual impairment

Disability: 50%

Test Impression: On the basis of brief clinical history, developmental history,

clinical observation and psychological test findings it can be concluded that patient
has mild level of intellectual impairment at present.

DIAGNOSTIC FORMULATION

Points in Favour: Seizures are well-controlled with medication.

Memory of seizure episodes suggests partial or focal seizure activity.

Points in Against: One episode of seizure occurred when medication was missed, indicating
reliance on medication for control.

PROGNOSIS: Favourable, as the seizures are well-managed with medication.

DIFFERENTIAL DIAGNOSIS:

Epilepsy (controlled with medication)

MANAGEMENT PLAN:

Continue with prescribed medication to prevent further seizures.

Regular follow-up to monitor the effectiveness of the treatment and adjust as necessary.

Education for the parents on the importance of adherence to medication.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.:17

IPD No.: 918088

SOCIO-DEMOGRAPHIC DETAILS:
Name: H

Age: 11

Gender: Male

Education: 3RD

Occupation: Student

Marital Status: N/A

Socio-economic Status: Lower

Locality: rural

Referred By: Department of Paediatric

Informant: Mother

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “padhne mai amnn nhi lgta hai”

“koi dost nhi hai”

Informant: “jhatke aate hai”

“jab jhatke band hote hai toh bht zda sir dukhta hai”

“dukan pe kuch saman lene bhejo toh kuch aur he le aata hau”

“padhaii mai kamzor hai”

HISTORY OF PRESENT ILLNESS (HOPI):

An 11-year-old male patient was brought to the OPD by his parents. He was born at full term
with a birth weight of 3 kg, and his developmental milestones were achieved on time. The
parents reported that the patient experiences seizures, which occur approximately once every
4-5 months. Following the seizures, he suffers from severe headaches. Additionally, when
sent to a shop to buy something, he often returns with the wrong item. The patient has no
friends and struggles significantly in his studies. There is also a family history of mental
illness, as his uncle is affected by it.

Onset: The onset of seizures began at an unspecified time but occur with a frequency of
approximately once every 4-5 months.

Course: Continuous

Progress of illness: static

Precipitating Factors: There are no specific events or triggers identified that precipitate the
onset of the seizures.

Predisposing Factors: The patient's uncle has a mental illness, suggesting a possible genetic
predisposition.

Perpetuating Factors: The patient has no friends, performs poorly in studies, and struggles
with daily tasks such as shopping, which could perpetuate cognitive and social difficulties.

Protective Factors N/A

Negative History:- No history suggestive of head injury.

-no history suggestive of psychiatric illness.

PAST MEDICAL HISTORY: No

PAST PSYCHIATRIC HISTORY: No

FAMILY HISTORY: The patient's uncle has a mental illness.

PERSONAL HISTORY:

Birth and Early Development: He was born at full term with a birth weight of 3 kg, and his
developmental milestones were achieved on time

Childhood History: the patient had difficult childhood as he suffered from seizure and had
no friend while growing up.

Education and Schooling History: he is currently studying in class 3rd

Occupation History: student

PRE-MORBID PERSONALITY:

Social Relations: The patient has no friends, indicating social isolation. The family dynamic
includes a history of mental illness, as his uncle is affected.
Intellectual Activities, Hobbies and Use of Leisure time: likes to play with his toys

Pre-dominant Mood of patient: frustration or low mood could be inferred due to social
isolation and academic difficulties.

Character:

 Attitude towards Self: not reported

 Attitude to work or responsibility: Struggles with responsibility, as seen in his
difficulty with tasks like shopping.
 Interpersonal relationships: Lacks friendships, indicating difficulties in social
interaction.
 Moral and religious attitudes and standards: not reported

Habits:

The patients eating and sleeping habits are normal

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: the patient came in with the general appearance and
was not cooperative with the examiner

Psycho-Motor Activity: no abnormalities

Speech: normal speech

Mood and Affect: low, given his social isolation and academic struggles, but this is not
explicitly stated.

Thought:

 Stream: no abnormalities
  Form: no abnormalities
 Possession: no abnormalities
 Content: impacted by the cognitive challenges and headaches to post seizure

Perception: no abnormalities

Cognition: The patient exhibits difficulties in cognitive tasks, such as purchasing the correct
items when sent to a shop

Judgment: impaired, as evidenced by his poor performance in studies and tasks.

Insight: no abnormalities

IMPRESSION: Mild Intellectual Impairment

PSYCHOLOGICAL ASSESMENT:
Rationale for Psychological Assessment his lack of concentration in studies

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
12- Binet Kamat Test (BKT)

Family History- There is a family history of mental health issues, with his uncle.
Negative History – history of seizures over the past year

Behavior Observation during Testing-

The patient presented with a general appearance, but faced challenges in maintaining eye
contact. Furthermore, the patient seemed disoriented, lacking awareness of time and date. It
was also challenging to capture and sustain the patient's attention for the necessary duration.
Conducting the test was quite challenging, as the patient required multiple prompts and
instructions during the assessment.

 Binet Kamat Test

• . Mental Age: 76 months (6years 4 months)
• I.Q.: 58 Mild level of intellectual impairment

Disability: 50%

Test Impression: On the basis of brief clinical history, developmental history,

clinical observation and psychological test findings it can be concluded that patient
has mild level of intellectual impairment at present.

DIAGNOSTIC FORMULATION:

Points in Favour: The presence of seizures, cognitive difficulties, poor academic

performance, social isolation, and family history of mental illness.

Points in Against: Lack of detailed information on the patient’s mood, speech, general
behaviour, and habits.

PROGNOSIS: The prognosis is uncertain without further diagnostic evaluation, but the
static nature of the illness suggests a need for ongoing management.

DIFFERENTIAL DIAGNOSIS: Epilepsy, cognitive disorder, and potential genetic or

inherited neurological conditions.

MANAGEMENT PLAN: Comprehensive neurological evaluation, cognitive assessment,

and consideration of genetic counselling. Supportive measures to address social isolation and
academic challenges, possibly including special education services or therapy.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.: 18

IPD No.: 920341

SOCIO-DEMOGRAPHIC DETAILS:

Name: V S
Age: 4

Gender: Male

Education: Nursery

Occupation: Student

Marital Status: N/A

Socio-economic Status: Lower Middle

Locality: Urban

Referred By: Department of Paediatrics

Informant: Mother

Reliability of Information: (Satisfactory/Unsatisfactory)

Adequacy of Information: (Adequate/Inadequate)

CHIEF COMPLAINTS:

Patient: “ the patient doesn’t spaeak”

Informant: “bolta nhi hai”

“2 letter words he bolta hai”

“jab 6 months ka tha tabse jhatke aate hai”

“8-10 din mai seizure aata hai”

“ek bar stairs se gir gaya tha”

“linear displaced fracture of the left side. Frontal bone with underlining extracranial
haemorrhage measuring 4mm in thickness.”

“his RCB WBC and haemoglobin are high “

HISTORY OF PRESENT ILLNESS (HOPI):

A 4-year-old male patient presented to the OPD with his parents. He was born prematurely at
8 months with a birth weight of 2 kg and had a birth cry at birth. He started walking at the age
of 2 but has significant delays in speech, only speaking two-letter words. The patient is
described as very hyperactive. He experienced his first seizure at 6 months old, and his
seizures now recur every 8-10 days.

The patient also has a history of a significant head injury, where he fell down the stairs,
leading to a linear displaced fracture of the left frontal bone. This injury required 20 stitches
externally and 20 internally, with an underlying extracranial hemorrhage measuring 4mm in
thickness. His recent blood tests show elevated levels of RBCs, WBCs, and haemoglobin.

This summary highlights the key medical history and current concerns for this patient, which
would be important for further evaluation and treatment planning.

Onset: The patient's condition began with his first seizure at 6 months of age

Course: Continuous

Progress of illness: fluctuating

Precipitating Factors: The initial seizure episode at 6 months may have triggered the onset of
his current neurological issues

Predisposing Factors: Born prematurely at 8 months with a low birth weight of 2 kg. Potential
environmental or genetic factors might have predisposed him to his current condition, though
specific details aren't provided

Perpetuating Factors: The history of head injury with a linear displaced fracture and
underlying extracranial hemorrhage may be perpetuating his condition. The lack of
significant language development and hyperactivity could also be related to the ongoing
neurological issues

Protective Factors: No specific protective factors are identified in the current information.
Negative History:- no history suggestive of psychiatric illness.

-no history suggestive of harmful substance

PAST MEDICAL HISTORY: Premature birth at 8 months with a birth weight of 2 kg.

Seizures began at 6 months and recur every 8-10 days.

History of significant head injury from falling down stairs, resulting in a linear displaced
fracture of the left frontal bone and underlying extracranial hemorrhage.

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: not reported

PERSONAL HISTORY:

Birth and Early Development: He was born prematurely at 8 months with a birth weight of
2 kg and had a birth cry at birth. He started walking at the age of 2 but has significant delays
in speech, only speaking two-letter words. The patient is described as very hyperactive. He
experienced his first seizure at 6 months old, and his seizures now recur every 8-10 days.
Childhood History: he had a difficult childhood as he couldn’t speak and he had seizure

Education and Schooling History: Nursery

Occupation History: Student

PRE-MORBID PERSONALITY:

Social Relations:

The patient is described as having no friends and is likely isolated socially

Intellectual Activities, Hobbies and Use of Leisure time: likes to play with toys.

Pre-dominant Mood of patient: his hyperactivity and language delays may suggest
frustration or other emotional responses related to his developmental challenges.

Character:

 Attitude towards Self: delays and hyperactivity may influence self-perception.

 Attitude to work or responsibility: N/A
 Interpersonal relationships: Limited due to his isolation from peers and
developmental delays.
 Moral and religious attitudes and standards: N/A

Habits:

The eating and sleeping patterns are normal

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: the patient came in with general appearance and had
cooperative behaviour towards examiner
Psycho-Motor Activity: Hyperactive with ongoing seizures.

Speech: Limited to two-letter words, with significant delays in language development.

Mood and Affect: influenced by developmental delays and ongoing seizures.

Thought:

 Stream: N/A
 Form: N/A
 Possession: N/A
 Content: N/A

Perception: N/A

Cognition: Delayed, with difficulty in speech and hyperactivity impacting cognitive

function.

Judgment: N/A

Insight: N/A

IMPRESSION: Below Average level of socio adaptive functioning

PSYCHOLOGICAL ASSESMENT:
Rationale for Psychological Assessment seizures and lack of social relation

Areas to be Investigated Evaluation for diagnostic clarification

 Test Administered
13- Vineland Social Maturity Scale (VSMS)
14- Developmental Screening Test (DST)
Behavior Observation during Testing-
The overall appearance of the patient seemed typical. However, he exhibited challenges in
maintaining eye contact and was not easily responsive to attempts to capture his attention.
The patient displayed impatience and prevented his mother from speaking. Establishing
rapport with the patient proved to be challenging.

Test Findings:
 Vineland Social Maturity Scale Social Age: 42 months
Social Quotient: that is 87 which means he has below average level of social adaptive
functioning.
Pattern Analysis of Vineland Social Maturity Scale (VSMS)
S.no Social Social Age Social Quotient Interpretation
Areas/Domain (Months)
39. Self Help 32 67 Mild level
General
40. Self Help 76 158 Genius
Eating
41. Self Help 84 175 Genius
Dressing
42. Self-Direction N/A N/A N/A
43. Occupation 44 92 Average level
44. Communication 40 83 Below average
level

Locomotion 52 108 Average level

7.

8. Socialization 60 125 Superior+

level
 
Test Interpretation: 87 social quotient that indicates that the patient has
below average level of social adaptive functioning
Developmental Screening Test

 Developmental Age: 28 months

• Developmental Quotient: 59 is mild level of developmental behaviour functioning

 Test Interpretation: 59 developmental quotient that indicates tha the patient has
mild level of developmental functioning.

 Test Impression: On the basis of brief clinical history, developmental history,

clinical observation and psychological test findings it can be concluded that
patient has below average level of socio adaptive and intellectual functioning
and mild level of development quotient at present.

DIAGNOSTIC FORMULATION:

Points in Favour: Premature birth and head injury contribute to current developmental issues
and seizures.

Points in Against: No other significant medical or psychiatric history provided that would
suggest alternative diagnoses.

PROGNOSIS: Prognosis is uncertain due to the ongoing nature of seizures and

developmental delays. Continuous medical management and developmental support are
essential.

DIFFERENTIAL DIAGNOSIS:

Epileptic disorder due to recurrent seizures.

Developmental delay or language disorder.

Possible post-traumatic sequelae from head injury.

MANAGEMENT PLAN:

Medical Management: Regular monitoring and treatment for seizures.

Developmental Support: Speech and language therapy.

Occupational therapy for developmental delays.

Family Support: Counselling and support for parents to manage the patient's condition and
development.

Follow-up: Regular follow-up appointments to monitor progress and adjust treatment as

needed.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.: 19

OPD No.: 14978115

SOCIO-DEMOGRAPHIC DETAILS:

Name: A C

Age: 11

Gender: Male

Education: No Education

Occupation: N/A

Marital Status: N/A

Socio-economic Status: Lower Middle

Locality: Urban

Referred By: MGM Medical Collage

Informant: Mother

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “mujhe nhi pta hai kyu lae hai”

Informant: “subha uthta hai jladi aur uthte se he chai lgti hai”

“subha uthte se he bhr chle jata hai”

“apni choti bhen ko marta hai”

“dusre bacchoke ko bht marta hai”

“jab 5 saal ka hua uske baad uske jhatke aane shuru hue”

“agar dawaii na do toh jhatke aa jate hai”

“15 din nicu mai admit tha”

“jab 5 saal ka hua toh sabse pehele muh moda uske baad gardan modi aur phr jhatke aane
lge”

“sahi se bol nhi pata hai haklata hai”

HISTORY OF PRESENT ILLNESS (HOPI):

An 11-year-old male patient presented to the OPD with his parents. He was born at full term,
weighing 3 kg, with a birth cry delayed by 2 minutes. At 15 days old, he was admitted to the
NICU due to symptoms resembling vomiting and experienced stiffness in his hands and legs.
His developmental milestones, including sitting, walking, and speaking, were delayed. At age
5, he exhibited a facial expression and turned his neck, followed by a seizure. He continues to
have seizures if not on medication. The patient shows aggressive behaviour, such as hitting
other children and teasing his younger sister. He wakes up at 6 a.m., drinks tea, and
immediately leaves the house. He can remember the names of foods he eats but not those he
doesn't.

Onset: The patient's condition began early in life, with symptoms manifesting as early as 15
days old, when he was admitted to the NICU due to vomiting-like symptoms and stiffness in
his limbs

Course: continuous

Progress of illness: static

Precipitating Factors: The specific trigger for the initial symptoms at 15 days old is unclear,
but the onset of seizures at age 5 was preceded by facial and neck movements.

Predisposing Factors: patient's delayed developmental milestones and neurological symptoms

may have a genetic or prenatal origin. His overall health and diet at an early age could also be
considered, though no explicit factors are provided.

Perpetuating Factors The patient's aggressive behavior, lack of social interactions (e.g.,
teasing his sister), and possibly inadequate supervision (immediately leaving the house after
waking) could be perpetuating factors. Lack of structured activities and a supportive
environment may also contribute.
Protective Factors: Consistent medication management for seizures could be considered a
protective factor.

Negative History:- no history suggestive of trauma

-no history suggestive of harmful substance

PAST MEDICAL HISTORY: Delayed developmental milestones (sitting, walking,

speaking).

Seizures beginning at age 5, continuing without medication.

PAST PSYCHIATRIC HISTORY: not reported

FAMILY HISTORY: not reported

PERSONAL HISTORY:

Birth and Early Development: . He was born at full term, weighing 3 kg, with a birth cry
delayed by 2 minutes. At 15 days old, he was admitted to the NICU due to symptoms
resembling vomiting and experienced stiffness in his hands and legs. His developmental
milestones, including sitting, walking, and speaking, were delayed. At age 5, he exhibited a
facial expression and turned his neck, followed by a seizure

Childhood History: he had a difficult childhood as he suffered from seizure and other
medical conditions.

Education and Schooling History: the patient didn’t go to school

Occupation History: N/A

PRE-MORBID PERSONALITY:

Social Relations: The patient exhibits aggressive behavior, particularly towards other
children, and teases his younger sister. He seems to lack strong social connections outside the
family, as there is no mention of friendships or other supportive relationships.

Intellectual Activities, Hobbies and Use of Leisure time: he likes to play outside the house.

Pre-dominant Mood of patient: The patient appears to have a disruptive and possibly
irritable mood, given his aggressive actions towards others and teasing behavior.

Character:

 Attitude towards Self: underlying frustrations or low self-esteem.

 Attitude to work or responsibility: behaviour indicates a lack of responsibility or
discipline, particularly in social interactions.
 Interpersonal relationships: The patient has strained interpersonal relationships,
especially within the family, as evidenced by his aggression towards other children
and teasing of his sister.
 Moral and religious attitudes and standards: not reported

Habits:

Normal eating and sleeping habits

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: the patient came in with general appearance and he
wasn’t cooperative with examiner
Psycho-Motor Activity: aggressive tendencies suggest possible hyperactivity or
impulsiveness.

Speech: The patient has delayed speech development

Mood and Affect: The patient appears irritable or disruptive based on his aggressive and
teasing behaviors.

Thought:

 Stream: n abnormalities
 Form: no abnormalities
 Possession: no abnormalities
 Content: no abnormalities

Perception: no abnormalities

Cognition: cognition may be impaired, as suggested by his delayed developmental

milestones and selective memory issues.

Judgment: impaired, given the patient’s aggressive behavior and lack of social
understanding.

Insight: poor, as there is no indication that the patient recognizes or understands the impact
of his behavior.

IMPRESSION: Moderate level of socio adaptive functioning.

 PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment his behavioural issues

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
15- Vineland Social Maturity Scale (VSMS)
16- Seguin Form Board Test
17- Binet Kamat Test

Behavior Observation during Testing-

The overall appearance of the patient seemed typical. However, he exhibited challenges in
maintaining eye contact and was not easily responsive to attempts to capture his attention.
The patient displayed impatience and prevented his mother from speaking. Establishing
rapport with the patient proved to be challenging.

Test Findings:
 Vineland Social Maturity Scale Social Age: 47 months
Social Quotient: that is 37 which means he has moderate level of social adaptive
functioning.

Pattern Analysis of Vineland Social Maturity Scale (VSMS)

S.no Social Social Age Social Quotient Interpretation
Areas/Domain (Months)
45. Self Help 12 25 severe level
 General
46. Self Help 32 67 mild Genius
Eating

47. Self Help 56 116 Above average

Dressing level
48. Self-Direction N/A N/A N/A
49. Occupation 60 125 superior level
50. Communication 40 83 Below average
level

Locomotion 28 58 mild level

7.

8. Socialization 44 92 average
level

 Test Interpretation: 37 social quotient that indicates that the patient has
below average level of social adaptive functioning

Seguin Form Board Test

The patient couldn’t perform the test.

Binet Kamat Test

The patient couldn’t perform the test

DIAGNOSTIC FORMULATION:

Points in Favour: History of seizures.

Delayed developmental milestones.

Aggressive behavior.

Selective memory for food names.

Admission to NICU with early symptoms.

Points in Against: Lack of detailed psychiatric history.

No family history of similar issues mentioned.

PROGNOSIS: The prognosis may be guarded, depending on the underlying neurological

condition. With proper management, including medication adherence for seizures and
possible behavioural interventions, there may be potential for improvement.

DIFFERENTIAL DIAGNOSIS: Neurodevelopmental Disorder (e.g., Autism Spectrum

Disorder with epilepsy).

Childhood-Onset Epilepsy with Behavioral Dysregulation.

Intellectual Disability with Behavioral Challenges.

ADHD with comorbid seizures.

MANAGEMENT PLAN:

Medication: Continue with anticonvulsants to manage seizures.

Behavioral Therapy: Implement strategies to address aggression and improve social skills.

Cognitive Assessment: Conduct a full cognitive evaluation to assess intellectual functioning.

Family Support: Provide education and support to the family to manage the patient’s
behaviors at home.
Follow-Up: Regular follow-ups to monitor seizure control, behavior, and developmental
progress.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.: 20

OPD No.: 15026816

SOCIO-DEMOGRAPHIC DETAILS:
Name: T

Age: 17

Gender: Female

Education: 10TH

Occupation: Student

Marital Status: N/A

Socio-economic Status: Middle

Locality: Sub-urban

Referred By: Department of Psychiatry

Informant: Father

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “padhaii mai mann nhi lgta”

Informant:

“jab 5 saal ki thi mummy ki death ho gyi thi”

“padhne mai starting se weak hai”

“padhne ki koshish bhi nhi karti hai”

“10th ki exam 2 bar di hai”

HISTORY OF PRESENT ILLNESS (HOPI):

A 17-year-old female patient visited the OPD with her family. She was born at full term with
a birth weight of 2 kg, but her birth cry was delayed. She didn't begin walking until the age of
3, and her speech is slurred. Her mother passed away when she was 5 years old. The patient
has struggled academically from the beginning and had to take her class 10th exams twice.
She has little interest in studying. During her mother's pregnancy, at around 3 months, her
mother experienced paralysis and later developed hepatitis B.

Onset: The patient's difficulties began from birth, with delayed crying and low birth weight.
Developmental milestones such as walking were significantly delayed, beginning only at age
3.

Course: continuous

Progress of illness: static

Precipitating Factors: The mother’s experience of paralysis and subsequent development of

hepatitis B during pregnancy might have contributed to the onset of the patient’s
developmental issues.

Predisposing Factors: The mother's health complications during pregnancy, including

paralysis and hepatitis B, could have predisposed the patient to developmental delays.

Perpetuating Factors: The loss of her mother at age 5, combined with a lack of interest in
studies and possibly limited academic support, may have perpetuated her ongoing difficulties.

Protective Factors: The patient's supportive family presence

Negative History:

PAST MEDICAL HISTORY: not reported

PAST PSYCHIATRIC HISTORY: not significant

FAMILY HISTORY: mother's pregnancy, at around 3 months, her mother experienced

paralysis and later developed hepatitis B.
PERSONAL HISTORY:

Birth and Early Development: She was born at full term with a birth weight of 2 kg, but her
birth cry was delayed. She didn't begin walking until the age of 3, and her speech is slurred.

Childhood History: she had a difficult childhood as her mother died when she was 5.

Education and Schooling History: 10th

Occupation History: Student

Menstrual History: she started her periods at the age of 12

PRE-MORBID PERSONALITY:

Social Relations: The patient has a limited social network, with her family being the primary
source of support. The early loss of her mother likely impacted her social development and
relationships.

Intellectual Activities, Hobbies and Use of Leisure time: she likes to paint

Pre-dominant Mood of patient: experiences a low mood, influenced by her academic

struggles and the loss of her mother.

Character:

 Attitude towards Self: low self-esteem due to her academic failures and
developmental delays.
 Attitude to work or responsibility: She appears to have a negative attitude towards
studying, as evidenced by her lack of interest and the need to retake exams.
  Interpersonal relationships: The patient may have difficulties in forming and
maintaining relationships, influenced by her developmental delays and the early loss
of her mother.
 Moral and religious attitudes and standards: she visits to temple everyday
Habits:

She has a normal eating and sleeping habits

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: the patient came in with general appearance and her
behaviour towards the examiner was cooperative

Psycho-Motor Activity: reduced, considering her developmental challenges.

Speech: Slurred speech, as reported in the patient's history.

Mood and Affect: subdued or depressed, considering her struggles with academics and the
loss of her mother.

Thought:

 Stream: slow or disorganized, considering her developmental delays.

 Form: simplistic due to cognitive challenges
 Possession: no abnormalities
 Content: focused on her struggles and possibly her mother's death, though no specific
delusions or obsessions are mentioned.
Perception: no abnormalities

Cognition: impaired, as evidenced by delayed developmental milestones, academic

struggles, and slurred speech.

Judgment: impaired, especially in academic and social settings.

Insight: limited, as the patient may not fully understand the extent or nature of her
difficulties.

IMPRESSION: Mild Intellectual Impairment

PSYCHOLOGICAL ASSESMENT:
Rationale for Psychological Assessment lack of interest in studies

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
Malin’s Intelligence Scale for Indian Children (MISIC)

Binet Kamat Test

Behaviour Observation during Testing- o General Appearance: -

Her general appearance was well kempt and tidy.
o Language and communication: - Speech was stutter.
o Comprehension of test instructions: - Could comprehend test
instructions with some difficulty as she was not very cooperative
during the assessment.
o Attention concentration: Attention could not be sustained for
long period of time.

Test Description:

Verbal Intelligence is the ability to analyse information and solve problems

using language-based reasoning. Language-based reasoning may involve
reading, writing, listening to words, conversing, thinking, and from classroom
learning to social communication.
Verbal Tests IQ
Information 67
Comprehension 67
Arithmetic 61
Similarities 58
 Digit Span 125
Verbal IQ 76

Nonverbal intelligence is the ability to analyse information and solve

problems using visual or hands or reasoning.
Nonverbal Tests IQ
Picture Completion 64
Block Design 57
Object Assembly 59
Coding 86
Mazes 0
Performance IQ 54

On MISIC Intellectual Functioning, Tanvi performed up to an IQ of 54

(mild) On the verbal scale he performed up to IQ 76 (borderline) and
on the performance scale, she scored up to 65(mild) on full scale
intelligence quotient assessment.

Test Findings:
Verbal Intelligence Quotient: 76
Performance Intelligence Quotient: 54
Full Scale Intelligence Quotient: 65
Test Interpretation: on the basis of the test, it can be concluded that
patient has mild level of intelligence.

 Binet Kamat Test

• . Mental Age: 80 months (6year 6month)
• I.Q.: 42 moderate level of intellectual impairment

Disability: 50%

Test Interpretation: On the basis of test findings, it can be concluded that patient has
mild level of intellectual impairment at present.
 Test Impression

On the basis of brief clinical history, developmental history, clinical observation and
psychological test findings it can be concluded that patient has mild level of
intellectual impairment at present according to Malin’s Intelligence Scale for Indian
Children and patient has moderate level of intellectual impairment at present
according to Binet Kamat Test.

DIAGNOSTIC FORMULATION:

Points in Favour: Prenatal complications (mother's paralysis and hepatitis B).

Delayed developmental milestones.

Repeated academic failure and lack of interest in studies.

Early maternal loss

Points in Against:

Lack of detailed information on cognitive assessment or social interactions beyond the

family.

No specific behavioral or psychiatric symptoms mentioned beyond developmental delays.

PROGNOSIS: Prognosis may be guarded due to the combination of developmental delays

and ongoing academic difficulties, but could improve with appropriate interventions,
including academic support and counseling.

DIFFERENTIAL DIAGNOSIS: Intellectual Disability

Developmental Delay

Learning Disorder

Depression or Adjustment Disorder (secondary to the loss of her mother)

MANAGEMENT PLAN:
Comprehensive cognitive and developmental assessment.

Academic support and individualized education plan (IEP).

Counseling to address grief and loss related to her mother's death.

Family counseling to provide additional support and coping strategies.

Regular follow-up to monitor progress and adjust interventions as needed.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology
 CASE HISTORY No.: 21

OPD No.: 15030749

SOCIO-DEMOGRAPHIC DETAILS:

Name: V P

Age: 3

Gender: Male

Education: N/A

Occupation: N/A

Marital Status:N/A

Socio-economic Status: Middle

Locality: Sub-urban

Referred By: Department of Audio and Speech

Informant: Family

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “patient couldn’t speak”

Informant: “sunai bht kam deta hai”

“bolti bhi nhi hai”

HISTORY OF PRESENT ILLNESS (HOPI):

A 3-year-old female patient was brought to the OPD by her parents. She was born at full term
(9 months) via C-section, with a birth weight of 3 kg and a present birth cry. While she began
walking on time, her speech has not yet developed, and her hearing is significantly impaired.
There is a family history of similar conditions, as her aunts' daughters are also unable to
speak or hear.

Onset: The patient has had delayed speech development and significant hearing impairment
from early childhood.

Course: continuous

Progress of illness: static

Precipitating Factors: There is no specific event or trigger identified as causing the onset of
the current problem.

Predisposing Factors: The patient's condition may be influenced by genetic factors, as

evidenced by the family history of hearing and speech impairments.

Perpetuating Factors: The patient's condition may be perpetuated by the lack of effective
intervention or supportive measures at home or in her environment.

Protective Factors Protective factors include early diagnosis and potential access to medical
care that could help manage or mitigate the condition.

Negative History: - no history suggestive of head injury.

-no history suggestive of exposure to harmful substance.

PAST MEDICAL HISTORY: N/A

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: The patient's family history is significant, as her aunt's daughters also
have speech and hearing impairments.
PERSONAL HISTORY:

Birth and Early Development: She was born at full term (9 months) via C-section, with a
birth weight of 3 kg and a present birth cry. While she began walking on time, her speech has
not yet developed, and her hearing is significantly impaired.

Childhood History: she had a difficult childhood as she can not speak or hear.

Education and Schooling History: she didn’t go to school

Occupation History: N/A

PRE-MORBID PERSONALITY:

Social Relations: The patient’s social interactions, particularly within her family, may be
limited due to her hearing and speech impairments.
Intellectual Activities, Hobbies and Use of Leisure time: Given her young age and her
developmental delays, the patient’s engagement in intellectual activities and hobbies might be
minimal.

Pre-dominant Mood of patient: she exhibits frustration or withdrawal due to her

communication challenges.

Character:

 Attitude towards Self: N/A

 Attitude to work or responsibility: N/A
 Interpersonal relationships: patient’s ability to form interpersonal relationships may
be impacted by her speech and hearing impairments.
 Moral and religious attitudes and standards: N/A

Habits:

Her eating and sleeping habits are normal

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: The patient likely appears developmentally

appropriate for her age, but with noticeable communication difficulties.

Psycho-Motor Activity: No specific abnormalities in psychomotor activity are mentioned

Speech: The patient has not yet developed speech, which is a significant area of concern.

Mood and Affect: signs of frustration or withdrawal due to her communication challenges.

Thought:
  Stream: N/A
 Form: Undeveloped
 Possession: N/A
 Content: N/A

Perception: N/A

Cognition: No abnormalities

Judgment: N/A

Insight: N/A

IMPRESSION: Average level of Socio Adaptive Functioning

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment referred for IQ for cochlear implant

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
18- Vineland Social Maturity Scale (VSMS)
.
Behavior Observation during Testing-
The patient presented with a general appearance. Furthermore, the patient seemed
disoriented, lacking awareness of time and date. It was easy to capture and sustain the
patient's attention for the necessary duration.

Test Findings:
 Vineland Social Maturity Scale Social Age: 44 months
Social Quotient: that is 101 which means he has average level of social adaptive
functioning.

Pattern Analysis of Vineland Social Maturity Scale (VSMS)

S.no Social Social Age Social Quotient Interpretation
Areas/Domain (Months)
51. Self Help 52 133 superior level
General

52. Self Help 32 82 Below average

Eating level

53. Self Help 56 143 genius level

Dressing

54. Self-Direction N/A N/A N/A

55. Occupation 44 112 Above Average

level
56. Communication 40 102 average level

52 133 superior level

7. Locomotion

8. Socialization 44 112 Above average

level
  Test Interpretation: 101 social quotient that indicates that the patient has

average level of social adaptive functioning

DIAGNOSTIC FORMULATION:

Points in Favour: Family history of speech and hearing impairments.

Delayed speech development and significant hearing loss.

Normal birth and developmental milestones except for communication issues.

Points in Against: Lack of information about other potential contributing factors or

environmental influences.

No detailed assessment of cognitive development.

PROGNOSIS: The prognosis may depend on early intervention, including hearing aids,
speech therapy, and potential genetic counselling.

DIFFERENTIAL DIAGNOSIS: Congenital hearing loss with associated speech delay.

Genetic disorders related to hearing and speech.

Developmental language disorder secondary to hearing impairment.

MANAGEMENT PLAN:

Immediate audiological assessment to determine the extent of hearing loss.

Referral to a speech therapist for evaluation and intervention.

Genetic counselling to explore the family history and assess risks for other family members.

Continuous monitoring of cognitive and developmental milestones to identify any further

delays or issues.

Family education and support to ensure a conducive environment for the patient’s
development.

Assessment done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology
 CASE HISTORY No.: 22

OPD No.: 15151430

SOCIO-DEMOGRAPHIC DETAILS:

Name: K P

Age: 5.5

Gender: Male

Education: KGI

Occupation: Student

Marital Status: N/A

Socio-economic Status: Middle

Locality: Urban

Referred By: Department of Audio and Speech

Informant: Parents

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “the patient’s speech is not developed”

Informant: “speech bht kam hai 2 letter word bolta hai”

“2 saal mai thoda bola tha phr bolna band kr diya”

“roya late that chla bhi late tha”

“ek jagha bethta nhi hai”

“papa dada dadi har chiz aage se aage kr dete hai toh isko kuch mangna nhi padhta”

“jo ye bolta h vo he krna padhta hai warna ghusse ho jata hai”

“mild se moderate autism hai isko”

HISTORY OF PRESENT ILLNESS (HOPI):

This 5-year-old male patient's history, including multiple head injuries, delayed speech, and
early loss of speech, combined with the autism diagnosis, suggests a complex developmental
profile. The influence of family dynamics, particularly the pre-emptive fulfilment of his
needs, might also contribute to his behavior and social development. Given the autism
diagnosis, early intervention with speech therapy, behavioral therapy, and structured routines
may help improve his communication and social skills. Additionally, monitoring his
environment to prevent further injuries and addressing any potential impact of his
grandfather's substance use on the household may be important.

Onset: The onset of the patient's condition appears to have begun early in life, particularly
after the head injuries at 4 and 7 months of age.

Course: continuous

Progress of illness: static

Precipitating Factors: The falls and head injuries at 4 and 7 months may have precipitated the
onset of the speech loss and further developmental delays.

Predisposing Factors: The mother's bleeding during the third month of pregnancy and the
potential genetic predisposition, as suggested by the late speech development in the patient's
aunt, may have predisposed the patient to developmental issues.

Family dynamics, where his needs are fulfilled without him asking, might also contribute to
his stubborn behavior and social challenges.

Perpetuating Factors: The overprotective family environment, where the patient’s needs are
met without any effort on his part, might be perpetuating his stubborn behavior and hindering
his social and emotional development.
The grandfather's use of alcohol and tobacco could contribute to an environment that may not
be conducive to the child's development.

Protective Factors: The diagnosis of autism and the family's attention to his needs, though
potentially overprotective, can be seen as protective factors in that they ensure he is well
cared for.

The family's possible awareness of his condition could lead to seeking appropriate therapies
and interventions, which would serve as a protective factor

Negative History: -no history suggestive of use of harmful substance

-no history suggestive of brain injury

PAST MEDICAL HISTORY: The patient experienced head injuries at 4 months, 7 months,
and 8 years, leading to developmental delays.

Diagnosed with mild to moderate autism.

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: The patient's grandfather uses alcohol and tobacco.

The patient's aunt also had delayed speech development.

The mother's pregnancy with the patient included bleeding during the third month.
PERSONAL HISTORY:

Birth and Early Development: the patient was born with full term delivery with 3kg weight.
His developmental milestone were delayed.

Childhood History: he had a difficult childhood as he doesn’t speak.

Education and Schooling History: KGI

Occupation History: Student

PRE-MORBID PERSONALITY:

Social Relations: The patient has a very close-knit family environment where his needs are
met without him having to ask.

Intellectual Activities, Hobbies and Use of Leisure time: N/A

Pre-dominant Mood of patient: The patient is described as stubborn, which may indicate a
mood that is often irritable or demanding when his needs are not met immediately.

Character:

 Attitude towards Self: The patient have developed a strong sense of self-reliance
due to his needs being met pre-emptively by his family.
 Attitude to work or responsibility: The patient’s attitude towards responsibility may
be underdeveloped, as his family fulfils his needs without him asking.
  Interpersonal relationships: The patient has strong familial relationships
 Moral and religious attitudes and standards: N/A

Habits:

Normal eating and sleeping habits

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: the patient came in with general appearance and his
behaviour was not cooperative towards examiner

Psycho-Motor Activity: normal

Speech: not developed

Mood and Affect: predominantly irritable or frustrated when his needs are not immediately
met.

Thought:

 Stream: impaired, given the speech loss and autism diagnosis.

 Form: underdeveloped for his age, with possible disruptions in normal thought
processing.
 Possession: N/A
 Content: N/A

Perception: N/A

Cognition: Cognitive development appears delayed, particularly in speech and social

understanding, consistent with his autism diagnosis.

Judgment: impaired or underdeveloped due to the developmental delays and overprotective

family environment.

Insight: limited insight into his condition, typical for his age and diagnosis.

IMPRESSION: Borderline level of socio adaptive functioning and Moderate level of

developmental functioning.
 PSYCHOLOGICAL ASSESMENT:
Rationale for Psychological Assessment speech delayed

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
19- Vineland Social Maturity Scale (VSMS)
20- Developmental Screening Test (DST)
21- Seguin Form Board Test (SFBT)

Behavior Observation during Testing-

The overall appearance of the patient seemed typical. However, he exhibited challenges in
maintaining eye contact and was not easily responsive to attempts to capture his attention.
The patient displayed impatience and prevented his mother from speaking. Establishing
rapport with the patient proved to be challenging.

Test Findings:
 Vineland Social Maturity Scale Social Age: 49 months
Social Quotient: that is 75 which means he has borderline level of social adaptive
functioning.

Pattern Analysis of Vineland Social Maturity Scale (VSMS)

S.no Social Social Age Social Quotient Interpretation
Areas/Domain (Months)
57. Self Help 52 80 Below average
General level
58. Self Help 28 43 Moderate level
Eating
59. Self Help 84 129 Superior level
Dressing
60. Self-Direction N/A N/A N/A
 61. Occupation 64 98 Average level
62. Communication 80 123 Above average
level

Locomotion 72 111 Above Average

7.
level
8. Socialization 68 105 Average
level

 Test Interpretation: 75 social quotient that indicates that the patient has
borderline level of social adaptive functioning

Developmental Screening Test

Developmental Age: 24 months
Developmental Quotient: 40 is moderate level of developmental behaviour
functioning

 Test Interpretation: 40 developmental quotient that indicates tha the patient has
moderate level of developmental functioning.

Seguin Form Board Test

The patient took an extended amount of time, which resulted in the test being invalid.

 Test Impression: On the basis of brief clinical history, developmental history,

clinical observation and psychological test findings it can be concluded that
patient has borderline level of socio adaptive and intellectual functioning and
moderate level of development quotient at present.

DIAGNOSTIC FORMULATION:

Points in Favour:

Multiple head injuries in early childhood.

Delayed speech development and subsequent loss of speech.

Overprotective familial environment.

Autism diagnosis.

Delayed motor development.

Points in Against:

No significant deterioration in the condition beyond the static developmental delays.

No history of seizures or other neurological symptoms that might suggest more severe
neurological impairment.

PROGNOSIS: The prognosis for the patient depends on early intervention and therapy.
While the family’s attention ensures his basic needs are met, it may hinder his social and
cognitive development if not addressed. With appropriate interventions, such as speech and
behavioral therapy, there is potential for improvement, but the progress may be slow and will
depend on consistent support.

DIFFERENTIAL DIAGNOSIS: Autism Spectrum Disorder (Primary Diagnosis)

Developmental Delay (Secondary to head injuries)

Intellectual Disability (Needs further assessment)

Speech Delay

MANAGEMENT PLAN:

Speech and Language Therapy: To address delayed speech development and improve
communication skills.

Behavioral Therapy: To manage stubborn behavior and promote independence in daily

activities.

Family Counseling: To educate the family on fostering independence in the child and not
fulfilling all his needs preemptively.
Regular Follow-Up: To monitor progress and adjust the management plan as needed.

Environment Modification: Ensure the home environment is safe to prevent further injuries
and reduce exposure to the grandfather's substance use.

Referral to Pediatric Neurology: To assess any possible neurological impact from head
injuries and further refine the diagnosis.

Supportive Educational Environment Enroll the child in a special education program tailored
to children with autism to enhance learning and social interaction skills.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.: 23

OPD No.: 15268408

SOCIO-DEMOGRAPHIC DETAILS:

Name: T P
Age: 10

Gender: Male

Education: 2ND

Occupation: Student

Marital Status: N/A

Socio-economic Status: Middle

Locality: Sub-urban

Referred By: Department of Paediatric

Informant: Family

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient:

“patient didn’t say anything”

Informant:

“school se complaint aati hai”

“school jta hai par book bhi nhi kholta hai”

“jis chiz ke liye rokte hai wohe krta hai”

“khana zda khata hai”

“spoon se khana bhi nhi aata hai”

“agar school mai h.w. milta hai toh page fad deta hai”

“chize zda yaad nhi rethi”

“agar padhne ka bolte hai toh sidhe mana kr deta hai”

“jo krne bolte hai vo nhi krta hai pr jis chix ka mna krte hai vo he krta hai”

HISTORY OF PRESENT ILLNESS (HOPI):

A 10-year-old male patient presented to the OPD with his family. He was born full-term at 9
months with a present birth cry. At birth, his tongue was stuck to the roof of his mouth.
Although his developmental milestones were achieved on time, he began speaking later than
expected. His parents frequently receive complaints from school regarding his lack of interest
in studying. While he attends school, he doesn’t open his notebook or complete his
homework, often tearing up the pages instead. He has a strong appetite and struggles to eat
with a spoon. He refuses to study and often does the opposite of what he’s told. He is prone
to overthinking, frequently appears sad, and has a deep fear of abandonment.

Onset: Insidious

Course: Continuous

Progress of illness: static

Precipitating Factors: not significant

Predisposing Factors: developmental delays

Perpetuating Factors: Lack of supportive relationships at home, potential issues at school

Protective Factors: not significant

Negative History:- no history suggestive of head injury.

PAST MEDICAL HISTORY: not significant

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: N/A

PERSONAL HISTORY:
Birth and Early Development: He was born full-term at 9 months with a present birth cry.
At birth, his tongue was stuck to the roof of his mouth. Although his developmental
milestones were achieved on time, he began speaking later than expected

Childhood History: he had a difficult childhood as he didn’t had a supportive family.

Education and Schooling History: 2nd

Occupation History: Student

PRE-MORBID PERSONALITY:

Social Relations: Lacks supportive relationships, which may be contributing to his

behavioural issues

Intellectual Activities, Hobbies and Use of Leisure time: not significant

Pre-dominant Mood of patient: Frequently appears sad and overthinks, indicating a

predominantly low mood.

Character:

 Attitude towards Self: Negative; refuses to engage in tasks like studying.

 Attitude to work or responsibility: Avoidant; does not complete schoolwork or
follow instructions.
 Interpersonal relationships: Struggles with authority and likely has difficulties with
peer relationships.
 Moral and religious attitudes and standards: not significant
Habits:

His eating patterns are not normal as he eats alot

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: came in with general appearance and attitude towards
examiner was not cooperative.

Psycho-Motor Activity: No specific abnormalities mentioned.

Speech: Delayed in onset, but no current abnormalities

Mood and Affect: Predominantly sad; affect likely blunted or restricted.

Thought:

 Stream: Normal
 Form: Logical and coherent
 Possession: no abnormalities
 Content: Preoccupied with negative thoughts, overthinks, and has fears of
abandonment.

Perception: No perceptual abnormalities noted.

Cognition: intact, though disengaged from academic tasks.

Judgment: impaired, especially in relation to schoolwork and following instructions.

Insight: Limited; does not recognize the importance of studying or following rules.
IMPRESSION: Moderate level of socio adaptive functioning and Mild level of Intellectual
Impairment

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment complaint from school

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered

22- Vineland Social Maturity Scale (VSMS)

23- Binet Kamat Test (BKT)

Behavior Observation during Testing-

The overall appearance of the patient seemed typical. However, he exhibited challenges in
maintaining eye contact and was not easily responsive to attempts to capture his attention.
The patient displayed impatience and prevented his mother from speaking. Establishing
rapport with the patient proved to be challenging.

Test Findings:

Vineland Social Maturity Scale Social Age: 53 months

Social Quotient: that is 44 which means he has moderate level of social adaptive
functioning.

Pattern Analysis of Vineland Social Maturity Scale (VSMS)

 S.no Social Social Age Social Quotient Interpretation
Areas/Domain (Months)
63. Self Help 52 43 moderate level
General
64. Self Help 32 27 Severe level
Eating
65. Self Help 60 50 mild level
Dressing
66. Self-Direction N/A N/A N/A
67. Occupation 60 50 mild level

68. Communication 40 33 severe level

Locomotion 52 50 mild level

7.

8. Socialization 40 33 severe level

 Test Interpretation: 44 social quotient that indicates that the patient has
moderate level of social adaptive functioning at present.

 Binet Kamat Test

• . Mental Age: 64 months (5years 3 months)

• I.Q.: 53 mild level of intellectual impairment

Disability: 50%

Test Impression: On the basis of brief clinical history, developmental history, clinical
observation and psychological test findings it can be concluded that patient has mild level of
intellectual impairment and moderate level of socio adaptive functioning at present
 DIAGNOSTIC FORMULATION:

Points in Favour: Delayed speech onset.

Persistent behavioral issues.

Fear of abandonment.

Overthinking and low mood.

Points in Against: No significant medical or psychiatric history.

No clear environmental or familial triggers.

PROGNOSIS: Guarded, depending on the implementation of interventions such as

behavioral therapy and family support.

DIFFERENTIAL DIAGNOSIS: Oppositional Defiant Disorder (ODD)

Attention Deficit Hyperactivity Disorder (ADHD)

Depression or anxiety disorder

Learning Disorder

MANAGEMENT PLAN:

Behavioral Therapy: Implement strategies to improve compliance with schoolwork and

reduce oppositional behavior.

Family Counseling: Address potential familial issues that may be contributing to the patient’s
behavior.
School Interventions: Work with school personnel to create a supportive learning
environment.

Regular Monitoring: Follow-up to assess progress and adjust the treatment plan as necessary.

Psychoeducation: Educate the family on the importance of consistent discipline and positive
reinforcement.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.: 24

 OPD No.: 15293914

SOCIO-DEMOGRAPHIC DETAILS:

Name: V S

Age: 10

Gender: Male

Education: N/A

Occupation: N/A

Marital Status: N/A

Socio-economic Status: Middle

Locality: Urban

Referred By: Self

Informant: Mother

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: patient doesn’t speak or hear

Informant: “bolta sunta nhi hai”

“2 saal ki age mai cochlear implant hua tha “

HISTORY OF PRESENT ILLNESS (HOPI):

A 10-year-old patient was brought to the OPD with his family. He was born full-term but was
overweight at birth. His birth cry was present, but his feeding was inadequate. At the age of
2, he underwent a cochlear implant. Although he attends school, he is not being promoted to
the next class. There is a family history where the patient’s uncle did not start speaking until
the age of 4.

Onset: The patient's difficulties began early in life, as feeding was inadequate shortly after
birth, and a cochlear implant was required at the age of 2.

Course: continues

Progress of illness: static

Precipitating Factors: The need for a cochlear implant at age 2 may have been a specific
event that contributed to the current challenges the patient is facing.

Predisposing Factors: The patient was born overweight and experienced inadequate feeding
early on, which may have predisposed him to the challenges he now faces.

Perpetuating Factors: The lack of academic promotion and possible gaps in support at home
or school may be perpetuating the patient's difficulties.

Protective Factors: The patient has a supportive family that has sought medical
intervention, such as the cochlear implant, which may help mitigate some of the challenges.

Negative History:- no history suggestive of

PAST MEDICAL HISTORY: The patient underwent a cochlear implant at age 2

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: There is a family history of delayed speech, with the patient’s uncle
not starting to speak until the age of 4.
PERSONAL HISTORY:

Birth and Early Development: A 10-year-old patient was brought to the OPD with his
family. He was born full-term but was overweight at birth. His birth cry was present, but his
feeding was inadequate.

Childhood History: he had a difficult childhood as he underwent a surgery

Education and Schooling History: he is currently in nursery

Occupation History: student

PRE-MORBID PERSONALITY:
Social Relations: The patient has a family that appears to be supportive, as they have sought
medical care and interventions for his condition.

Pre-dominant Mood of patient: low self-esteem.

Character:

 Attitude towards Self: not reported

 Attitude to work or responsibility: His attitude toward academic responsibilities
may be influenced by his challenges in keeping up with schoolwork.
 Interpersonal relationships: The patient may have difficulties in forming friendships
or maintaining relationships due to his developmental challenges.
 Moral and religious attitudes and standards: not significant

Habits: normal eating and sleeping habits

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: the patient came in with general appearance and
attitude towards the examiner was positive.

Psycho-Motor Activity: no abnormalities

Speech: not developed

Mood and Affect: impacted by his developmental and academic challenges, but specific
details are not provided.

Thought:

 Stream: N/A
  Form: N/A
 Possession: N/A
 Content: N/A

Perception: N/A

Cognition: cognitive challenges as indicated by his need for a cochlear implant and his
academic difficulties.

Judgment: impaired, as suggested by his academic performance and possible cognitive

difficulties.

Insight: The patient may have limited insight into his challenges due to his age and
developmental level.

IMPRESSION: Above average level of socio adaptive functioning and below average level
of Intelligence

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment his school wasn’t promoting him to the next class.

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
24- Vineland Social Maturity Scale (VSMS)

25- Seguin Form Board Test (SFBT)

Behavior Observation during Testing-

The overall appearance of the patient seemed typical. However, he exhibited challenges in
maintaining eye contact and was not easily responsive to attempts to capture his attention.
 The patient displayed impatience. Establishing rapport with the patient proved to be
challenging.

Test Findings:
 Vineland Social Maturity Scale Social Age: 132 months
Social Quotient: that is 110 which means he has above average level of social adaptive
functioning.

Pattern Analysis of Vineland Social Maturity Scale (VSMS)

S.no Social Social Age Social Quotient Interpretation
Areas/Domain (Months)
69. Self Help 88 73 Borderline level
General
70. Self Help 116 96 Average level
Eating
71. Self Help 156 130 Superior level
Dressing
72. Self-Direction 168 140 genius
73. Occupation 180 150 genius

74. Communication 80 67 mild level

Locomotion 116 96 Average level

7.

8. Socialization 168 140 Genius

 Test Interpretation: 110 social quotient that indicates that the patient has
above average level of social adaptive functioning

Seguin Form Board Test: 96 months

Intelligence Quotient: that is 80 below average level of intelligence.
  Test Impression: On the basis of brief clinical history, developmental history,
clinical observation and psychological test findings it can be concluded that
patient has above average level of socio adaptive and below average level of
intellectual functioning.

DIAGNOSTIC FORMULATION:

Points in Favour: History of cochlear implant surgery at age 2.

Overweight at birth and inadequate feeding early on.

Family history of delayed speech.

Points in Against: The absence of any significant head injury or psychiatric illness.

No mention of substance use or harmful behavior.

PROGNOSIS: The prognosis may be guarded, with the potential for improvement if the
patient receives appropriate interventions and support for both his hearing impairment and
academic challenges

DIFFERENTIAL DIAGNOSIS: Developmental delay due to hearing impairment.

Genetic predisposition to delayed speech.

Possible learning disability

MANAGEMENT PLAN:

Continued monitoring and support for the cochlear implant.

Educational interventions to assist with academic progress.

Speech therapy and other developmental support services.

Family counseling to provide support and strategies for managing the patient's challenges.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.: 25

OPD No.: 14345788

SOCIO-DEMOGRAPHIC DETAILS:

Name: K B

Age: 26

Gender: Female

Education: B.COM

Occupation: Student

Marital Status: N/A

Socio-economic Status: Middle

Locality: Urban

Referred By: Dr Reddy

Informant: Family

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “chize yaad nhi hoi hai”

Informant: “jab peda hui thi tab uski tongue uske muh se chipki hui thi”

“dimag kamzor hai”

“chize yaad nhi rethi hai”

“haklati hai”

HISTORY OF PRESENT ILLNESS (HOPI):

A 26-year-old female was brought to the OPD by her family. She was born prematurely, with
a present birth cry, and her developmental milestones were on time. Her tongue was stuck to
her mouth because of which she underwent operation. She has struggled academically since
childhood, and despite her efforts, she has significant difficulty remembering things. She
often forgets directions and cannot be trusted with money. Her appetite is poor, and she
frequently makes excuses when asked to perform tasks. She has very low self-confidence and
speaks with slurred speech.

Onset: insidious

Course: continuous

Progress of illness: static

Precipitating Factors: N/A

Predisposing Factors: Being born prematurely may be a predisposing factor contributing to

her cognitive difficulties.

Perpetuating Factors: Her low self-confidence, poor eating habits, and lack of a structured
support system may be perpetuating her condition

Protective Factors: Supportive family

Negative History:-no history suggestive of head injury

-no history suggestive of substance use

PAST MEDICAL HISTORY: underwent operation for tongue stuck to her mouth

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: N/A

PERSONAL HISTORY:

Birth and Early Development: She was born prematurely, with a present birth cry, and her
developmental milestones were on time

Childhood History: she had a difficult childhood as she under went a operation

Education and Schooling History: she completed her B.COM

Occupation History: Student

Menstrual History: she had her first period when she was 13

PRE-MORBID PERSONALITY:

Social Relations: supportive family

Intellectual Activities, Hobbies and Use of Leisure time: she likes to stich

Pre-dominant Mood of patient: confused

Character:
  Attitude towards Self: The patient has low self-confidence and struggles with self-
esteem.
 Attitude to work or responsibility: Shows reluctance and often makes excuses when
asked to perform tasks.
 Interpersonal relationships: strained due to cognitive difficulties and low self-
confidence.
 Moral and religious attitudes and standards: not reported
Habits:

Normal eating and sleeping habit

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: she came in with general appearance and her attitude
towards examiner was positive.

Psycho-Motor Activity: normal

Speech: slurred

Mood and Affect: affected by cognitive difficulties and low self-confidence.

Thought:

 Stream: Disorganized or disrupted due to memory issues.

 Form: N/A
 Possession: N/A

 Content: Struggles with remembering tasks and directions.

Perception: N/A

Cognition: difficulties with memory, attention, and recall.

Judgment: Impaired, as she cannot be trusted with money and has difficulty with daily tasks.

Insight: Limited insight into her condition due to cognitive difficulties.

IMPRESSION: Mild Intellectual Impairment

PSYCHOLOGICAL ASSESMENT:
Rationale for Psychological Assessment low self-confidence, Doesn’t remember anything

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
1- Wechsler Adult Performance Intelligence Scale (WAPIS): To know the
level of intelligence.

Behavioural Observation: Her general appearance was neat and tidy Touch with
surrounding was present. Eye contact was proper, social smile was present. Rapport
was easily established.

She answered all the questions asked.

• Attention Concentration: Attention was easy to arouse and sustain

• Comprehension of Test Instructions: Able to understand and follow verbal

instructions sufficiently.
• Language and communication: Speech was not fully developed
• Sensory Ability: - Difficulty in Vision- Absent -Difficulty in
Audition- Absent
• Motor Ability: - Fine Motor: Adequate -Gross Motor- Adequate

• Test Findings
Wechsler Adult Performance Intelligence Scale (WAPIS)

TEST SCALED SCORE

Picture completion 0

Digit symbol 6

Block Design 6

Picture Arrangement 5

Object assembly 3
 Total scaled score 20

IQ score = 61 Mild intellectual impairment.

Disability = 50%

DIAGNOSTIC FORMULATION:

Points in Favour: Premature birth, ongoing cognitive difficulties, low self-confidence, and
poor memory.

Points in Against: No clear evidence of organic brain disease or psychiatric history.

PROGNOSIS: The prognosis is uncertain, but the condition appears to be static with no
significant improvement or deterioration.

DIFFERENTIAL DIAGNOSIS:

Cognitive disorders (e.g., early-onset dementia)

Learning disabilities

Neurological conditions affecting memory and cognitive function

MANAGEMENT PLAN:

Medical Evaluation: Further neurological and cognitive assessment to rule out underlying
conditions.

Psychiatric Support: Consider counseling or cognitive behavioral therapy to address low self-
confidence and improve coping strategies.

Support Services: Implement support for daily tasks and memory aids.

Nutritional Counseling: Address poor eating habits with dietary planning and support.
Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288
 Sri Aurobindo Medical College and University, Indore, M.P.
Department of Clinical Psychology

CASE HISTORY No.: 26

OPD No.: 14426308

SOCIO-DEMOGRAPHIC DETAILS:

Name: D L

Age: 1.5

Gender: Female

Education: N/A

Occupation: N/A

Marital Status: N/A

Socio-economic Status: Middle

Locality: Sub-urban

Referred By: Department of ENT

Informant: Parents

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “speech is not developed”

Informant: “bolti nhi hai”

HISTORY OF PRESENT ILLNESS (HOPI):

A 1.5-year-old girl visited the outpatient department with her mother. She was born at full
term with a normal birth cry. According to the information provided, her developmental
milestones were met on schedule. However, she has not yet developed speech.

Onset: insidious

Course: continuous

Progress of illness: improving

Precipitating Factors: N/A

Predisposing FactorsN/A

Perpetuating Factors: NA/

Protective Factors: N/A

Negative History: -no history suggestive of head injury

PAST MEDICAL HISTORY: N/A

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: N/A

PERSONAL HISTORY:

Birth and Early Development: A 1.5-year-old girl visited the outpatient department with
her mother. She was born at full term with a normal birth cry. According to the information
provided, her developmental milestones were met on schedule. However, she has not yet
developed speech

Childhood History: N/A

Education and Schooling History: N/A

Occupation History: N/A

 PRE-MORBID PERSONALITY:

Social Relations: N/A

Intellectual Activities, Hobbies and Use of Leisure time: N/A

Pre-dominant Mood of patient: N/A

Character:

 Attitude towards Self: N/A

 Attitude to work or responsibility: N/A
 Interpersonal relationships: N/A
 Moral and religious attitudes and standards: N/A

Habits:

Normal sleeping and eating habits

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: normal sleeping and eating habits

Psycho-Motor Activity: N/A

Speech: not developed

Mood and Affect: N/A

Thought:

 Stream: N/A
 Form: N/A
 Possession:N/A
 Content: N/A

Perception: N/A
 Cognition: N/A

Judgment:N/A

Insight: N/A

IMPRESSION: Superior level of socio adaptive functioning

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment speech delay

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
26- Vineland Social Maturity Scale (VSMS

Chief Complaints-

1. “Bol aur sun nhi sakti”

Behavior Observation during Testing-

o General Appearance: - she came with her family. Her general appearance
was normal.
Language and communication: - Speech and hearing is not developed.

Test Findings:
 Vineland Social Maturity Scale Social Age: 23 months
 Social Quotient: 135 that is superior which means he has very superior level of social
adaptive functioning.
 Pattern Analysis of Vineland Social Maturity Scale (VSMS)
S.no Social Social Age Social Quotient Interpretation
Areas/Domain (Months)
75. Self Help 32 188 Very superior
General
 76. Self Help Eating 32 188 Very superior

77. Self Help N/A N/A N/A

Dressing

78. Self-Direction N/A N/A N/A

79. Occupation 32 188 Very superior

80. Communication 7.5 44 Moderate

7. Locomotion 52 306 Very superior

8. Socialization 40 235 Very superior

 Test Impression: On the basis of brief clinical history, developmental history,

clinical observation and psychological test findings it can be concluded that patient
has very superior level of socio adaptive functions

DIAGNOSTIC FORMULATION:

Points in Favour: Developmental milestones were achieved on time, indicating normal early
growth.

The child was born at full term with a normal birth cry, suggesting no immediate perinatal
complications.

Points in Against: The child has not developed speech by 1.5 years, which may be a concern
for delayed language development.
No additional information provided about any underlying conditions or family history that
might contribute to speech delay.

PROGNOSIS: The progress of the illness is improving, suggesting a positive outlook with
potential for developmental catch-up. Continued monitoring and support are recommended.
DIFFERENTIAL DIAGNOSIS:

Developmental Language Disorder

Autism Spectrum Disorder (ASD) (though other symptoms would need to be considered for
this diagnosis)

Hearing Impairment (not specified, but should be ruled out)

Intellectual Disability (less likely given the timely achievement of other milestones)

MANAGEMENT PLAN:

Speech and Language Assessment: Referral to a speech-language pathologist for a

comprehensive evaluation and early intervention if needed.

Regular Monitoring: Ongoing observation of developmental milestones to ensure continued

progress.

Parental Support: Providing guidance and support to parents for stimulating language
development at home.

Hearing Test: Conducting a hearing test to rule out any auditory issues that could affect
speech development.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288
 Sri Aurobindo Medical College and University, Indore, M.P.
Department of Clinical Psychology

CASE HISTORY No.: 27

OPD No.: 14458288

SOCIO-DEMOGRAPHIC DETAILS:

Name: K P

Age: 17

Gender: Male

Education: N/A

Occupation: N/A

Marital Status: N/A

Socio-economic Status: Middle

Locality: Sub-urban

Referred By: MGM Medical Collage

Informant: Family

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “the patient couldn’t speak

Informant: “bachpan se bolta nhi hai”

“ghusse bht ata hai”

“marne dodhta hai sbko”

HISTORY OF PRESENT ILLNESS (HOPI):

A 17-year-old male arrived at the outpatient department with his family. He was born full-
term but had a delayed birth cry. He began walking later than usual and has not spoken since
childhood. He was toilet trained by age 8. He exhibits significant aggression and frequently
chases after people to hit them.

Onset: insidious

Course: continuous

Progress of illness: static

Precipitating Factors: N/A

Predisposing Factors: The individual was born full-term but with developmental delays,
which could be a predisposing factor.

Perpetuating Factors The ongoing aggression and lack of speech continue to affect
interactions and behavior.

Protective Factors: N/A

Negative History:- no history suggestive of head injury

PAST MEDICAL HISTORY: N/A

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: N/A

PERSONAL HISTORY:

Birth and Early Development: . He was born full-term but had a delayed birth cry. He
began walking later than usual and has not spoken since childhood. He was toilet trained by
age 8

Childhood History: difficult childhood as he couldn’t speak

Education and Schooling History: N/A

Occupation History: N/A

PRE-MORBID PERSONALITY:

Social Relations: are not good

Intellectual Activities, Hobbies and Use of Leisure time: N/A

Pre-dominant Mood of patient: Aggressive

Character:

 Attitude towards Self: N/A

  Attitude to work or responsibility: N/A
 Interpersonal relationships: N/A
 Moral and religious attitudes and standards: N/A

Habits:

Normal eating and sleeping habits

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: came in with typical appearance. His attitude towards
examiner was cooperative

Psycho-Motor Activity: The patient exhibits high levels of aggression and physical activity,
including running after others in a threatening manner.

Speech: The patient has not spoken since childhood, suggesting a significant speech
impairment or non-verbal status.

Mood and Affect: The mood is likely to be irritable or aggressive, given the described
behavior.

Thought:

 Stream: disrupted, as the patient is non-verbal and aggressive.

 Form: N/A
 Possession: N/A
 Content: N/A

Perception: N/A

Cognition: N/A

Judgment: judgment might be impaired, as evidenced by aggressive behavior and running

after people to hit them.

Insight: N/A

IMPRESSION: Profound level of socio adaptive functioning

 PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment speech delay

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
27- Vineland Social Maturity Scale (VSMS)
28-
Behavior Observation during Testing-
o General Appearance: - he came with his family. His general appearance
was normal.
o Language and communication: - speech wasn’t developed. the patient
wasn’t able to maintain eye contact. His behavior is not age appropriate.
The patient was using gesture to communicate.

Test Findings:
 Vineland Social Maturity Scale Social Age: 18months
 Social Quotient: 10 that means he has profound level of socio adaptive functioning.
Pattern Analysis of Vineland Social Maturity Scale (VSMS)

S.no Social Social Age Social Quotient Interpretation

Areas/Domain (Months)
81. Self Help 20 10 profound
General
82. Self Help Eating 32 17 profound

83. Self Help 17 9 profound

Dressing
84. Self-Direction N/A N/A N/A

85. Occupation 44 23 Severe

 86. Communication 15 8 profound

87. Locomotion 22 12 profound

88. Socialization 22 12 profound

Test Impression: On the basis of brief clinical history, developmental history, clinical
observation and psychological test findings it can be concluded that patient has profound
level of socio adaptive functioning.

DIAGNOSTIC FORMULATION:

Points in Favour: History of delayed milestones (walking, speech).

Persistent aggression and non-verbal behavior.

Points in Against: Lack of specific precipitating factors or triggers.

PROGNOSIS: The prognosis is uncertain without further evaluation. The persistence of

aggression and non-verbal behavior suggests a chronic condition.

DIFFERENTIAL DIAGNOSIS: Autism Spectrum Disorder (given the developmental

delays and non-verbal status)

Intellectual Disability

Possible Neurodevelopmental Disorders

MANAGEMENT PLAN:

Comprehensive Evaluation: Assess developmental, cognitive, and behavioral aspects to

determine the underlying condition.

Behavioral Interventions: Implement strategies to manage aggression and improve social

behavior.
Speech and Language Therapy: To address the non-verbal status and potential
communication issues.

Psychiatric Consultation: For a detailed assessment and management of aggression and

behavioral issues.

Family Support: Educate and support the family in managing the patient’s behavior and
developmental needs.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288
 Sri Aurobindo Medical College and University, Indore, M.P.
Department of Clinical Psychology

CASE HISTORY No.:28

OPD No.: 14563457

SOCIO-DEMOGRAPHIC DETAILS:

Name: A S

Age: 42

Gender: Male

Education: 12TH

Occupation: N/A

Marital Status: Married

Socio-economic Status: Lower middle

Locality: Sub-urban

Referred By: MGM Medical Collage

Informant: Brother

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “was not responsive”

Informant: “nasaha karte the ganja, injection, bhang, daru.

“marte bhi the”

“bhar nahi jate hai”

“ek bat ko 10 bar puchte hai”

“paiso se trust nhi krte”

HISTORY OF PRESENT ILLNESS (HOPI):

A 42-year-old male patient arrived with his wife. He was born full-term with a normal birth
weight. The patient has a history of substance use, including injections, drugs, alcohol,
tobacco, and marijuana. He struggles to understand anything and repeatedly asks the same
question up to ten times. Their sexual relationship has been non-existent for the past 8-9
years. The patient has also begun to physically abuse his wife and cannot be trusted with
money. During his period of substance use, he stopped eating. Now, he stays at home and is
unable to function normally.

Onset: insidious

Course: continuous

Progress of illness: deteriorating

Precipitating Factors: N/A

Predisposing Factors: The patient has a history of substance use, including injections, drugs,
alcohol, tobacco, and marijuana, which may have predisposed him to his current condition.
Environmental factors such as availability of substances and lack of early intervention may
also have contributed.

Perpetuating Factors: The patient’s home environment lacks a supportive relationship, as

evidenced by the physical abuse toward his wife. His inability to manage money, lack of
trustworthiness, and ongoing substance use history contribute to the maintenance of his
condition. His social isolation, staying mostly at home, further perpetuates his mental health
issues.

Protective Factors N/A

Negative History: -no history suggestive of head injury

PAST MEDICAL HISTORY: N/A

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: N/A

PERSONAL HISTORY:

Birth and Early Development: He was born full-term with a normal birth weight.

Childhood History: his childhood was difficult as lack of resources

Education and Schooling History: he didn’t go to school

Occupation History: he was a photographer

Substance Use History: The patient has a history of substance use, including injections,
drugs, alcohol, tobacco, and marijuana

PRE-MORBID PERSONALITY:

Social Relations: The patient’s social relationships appear to be strained, particularly with
his wife, whom he has started to physically abuse.

Intellectual Activities, Hobbies and Use of Leisure time: N/A

Pre-dominant Mood of patient: Aggressive

Character:

 Attitude towards Self: N/A

 Attitude to work or responsibility: N/A
 Interpersonal relationships: Negative
 Moral and religious attitudes and standards: N/A

Habits: he has normal sleeping and eating habits

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: he came in with general apperiance

Psycho-Motor Activity: N/A

Speech: Developed

Mood and Affect: The patient’s mood appears to be confused and possibly irritable, with a
flat or inappropriate affect.

Thought:

 Stream: thought stream seems to be impaired, as he cannot comprehend situations

and repeats himself.
 Form: disorganized, leading to repetitive questioning.
 Possession: N/A
 Content: Content of thought could include confusion and frustration, but specific
delusions or obsessions are not detailed.

Perception: N/A

Cognition: The patient exhibits cognitive impairment, with difficulty understanding

situations and managing basic tasks.

Judgment: Judgment is severely impaired, as the patient cannot be trusted with money and
has become abusive.

Insight: The patient likely lacks insight into his condition, given his cognitive difficulties and
repetitive behavior.

IMPRESSION: Moderate Intellectual Impariment

 PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment use of substance

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
Test Administered and rational:
1-Rorschach Ink Blot Test to know the personality structure.

2- Binet Kamat Test

Clinical Observation and test behaviour: Patients general appearance was neat and well
kempt. Touch with surrounding was present. The patient failed to sustain eye contact for the
necessary duration and encountered difficulties in communication. When queried about the
ages of his children, the patient displayed a lack of knowledge regarding the matter. He
exhibited lethargy and reluctance to engage in testing activities, making it challenging to
capture his attention. The patient's responsiveness was notably sluggish. The patient exhibited
partial disorientation, lacking full awareness of time, place, date, day, and year. He was able
to understand and follow the test instructions which were given by the examiner. During the
Rorschach test, the patient took longer than usual to respond. The patient had to be prompted
to gather responses.
Rorschach Ink Blot:

Structural Summary:

Location Features Determinants Contents Approach

Zf= 16 Single H=0 I = DdS.Dd.W

ZSum=53 M= 0 (H) =0 II = D.D.D
ZEst = 52.5 FM =1 Hd = 0 III = D.D
m=0 (Hd)=0 IV = W Blends=0
W=6 FC = 1 Hx = 0 V=W
D = 11 CF = 1 A= 8 VI =D
Dd = 3 C=3 Ad =3 VII = Dd.D
S=1 Cn=0 (Ad)=0 VIII = W.Dd
DQ FC’=0 An=1 IX = D.W.D
+ = 10 C’F=0 Art=2 X = W.D.D
O =6 C’=0 Ay=0
V =4 FT=0 BT=0
V/+ =1 TF=0 Cg=0
T=0 CL=1
FV=0 Ex=0
VF=0 Fd=0
V=0 Fi=0 Special scores
FY=0 Ge=0 LVL1 LVL2
YF=0 Hh=0 DV=0 2
Y=1 Ls=0 INC=1 1
Fr=0 Na=0 DR=0 0
Rf=0 Sc=0 FAB=0 0
FD=2 Sx=0 ALOG=0
F=12 Xy=1 CON=1
Id=5 Raw Sum 6=4
(A)=0 Wgtd=17
(2)=11
AB= 0 PHR=0
AG=0 GHR =0
Form Quality COP=0 MOR = 0
FQx MQual W + D= CP=0 PER=0
+=0 + =0 +=0 PSV=3
o=5 o=0 o=5
u = 13 u=0 u=9
-=3 -=0 - =3

Ratios, percentages and Derivations

R = 21 L = 1.3
EB = 0:6 EA =6 EBPer =0 FC: CF + C =1:4 AG = 0
eb = 1:1 es = 2 D=4 Pure C = 3 a: p = 1:0
Adj es =3 Adj D = 3 SumC’: WsumC =0:6 Human Cont. =0
P=1
FM = 1 SUMY=1 WSUMC=6 Afr = 0.61 Pure H =0
m=0 SUMT=0 SUMC’=0 S=1 2AB+(ART+Ay) =2
Blends: R =0:21 ISOLATED R=0.09
CP = 0 Zd=0.5

a: p = 1:0 Sum6 =4 XA% =0.85 Zf=16 3r + (2)/R = 0.52

Ma: Mp =0 Lv2 = 3 WDA% = 0.82 W:D: Dd =6:11:3 Fr + rF = 0
Mor = 0 Wsum6 =17 X-%= 0.14 W:M = 6:0 SumV = 0
M- = 0 X+% = 0.23 DQ+ = 10 MOR = 0
Xu% = 0.61 DQv= 4 H: (H) + Hd + (Hd) =0

PTI = 4 DEPI =2 CDI =1 S-CON= 2. HVI=no OBS= no

Interpretation
There was a total of 21 responses on 10 cards, rendering the protocol valid for interpretation.
Findings suggests that the person has a more sturdy tolerance for stress than do most and is
far less likely to experience problem in control.
Scores also suggests that the need states are not being experienced in typical ways, or that
they are being acted on more rapidly than is the case for more people.

Findings suggests that the impact of stress typically creates considerable interference in some
of the customary patterns of thinking and behaviour.
Scores suggests that the person is being overwhelmed or flooded by emotions. It is a
condition in which very strong emotions interfere markedly with thinking and are especially
impairing too the abilities necessary for attention and concentration during decision making.
The intensity of these emotions is quite disruptive and typically, ideational or behavioural
impulsiveness occurs.

The patient is prone to mix feelings with thinking much of the time when coping is required.
However, the person is some what flexible in the use of the extratensive style and instances
will occur in which feelings are put aside in favour of a more clearly ideational approach.
The individual seems as willing as others with their particular coping styles to process and
become involved with emotionally tones stimuli.

Scores indicates some potentially serious modulation problems. People such as this are often
overly intense in their emotional displays and frequently convey impressions of
impulsiveness. This problem could be the product of control difficulties however, it is equally
possible that it reflects a less mature psychological organization in which the modulation of
affect is not regarded as being very important.

Scores suggests that more efforts have been invested in processing than might be expected.
The person is striving to accomplish more than maybe reasonable in light of current
functional capacities. If these tendencies occur in everyday behaviour, this probability of
failure to achieve objectives is increased and the consequent impact of those failure can often
include the experience of frustration.

Scores signifies that the patient has difficulties in shifting attention.

Scores also indicates that the person is an avoidant-extratensive. In this a person is inclined to
use, and be influenced by, feelings. They depend a great deal on external feedback and often
involved with trial-and-error behaviour when confronted with decision making necessities.

Findings indicates that the subject is prone to merge to mix feelings with thinking most of the
time, but instances will occur in which feelings are pushed aside in favour of an ideational
approach that affords careful consideration of various options.

The patient tends to react quickly to reduce the irritation created by the intrusion of peripheral
thoughts.

Test Impression:

In summary, the individual exhibits a strong stress tolerance and is less likely to encounter
control problems. However, findings suggest that their need states are not experienced in
typical ways, possibly being acted upon more rapidly than the norm.

Under stress, there is significant interference in customary thinking and behaviour, with
indications of being overwhelmed by intense emotions. This emotional intensity hampers
attention, concentration, and decision-making, often leading to impulsiveness, both
ideationally and behaviourally.

The person tends to blend feelings with thinking, especially in coping situations, but displays
some flexibility by occasionally prioritizing an ideational approach over emotions. They are
willing to engage with emotionally toned stimuli, aligning with their coping style.

Serious modulation problems are noted, marked by overly intense emotional displays and a
perceived impulsiveness. This could be attributed to control difficulties or a less mature
psychological organization where the regulation of affect is not highly valued.

The individual invests more effort in processing than expected, attempting to accomplish
beyond current functional capacities. This tendency may increase the likelihood of failure to
achieve objectives, leading to potential frustration.
Scores indicate difficulties in shifting attention, suggesting a challenge in redirecting focus
effectively. The person is identified as an avoidant-extratensive, relying heavily on feelings
and external feedback, often employing trial-and-error behaviour in decision-making
situations.

In essence, the individual's psychological profile reflects a nuanced interplay between stress
resilience, emotional overwhelm, modulation challenges, and coping styles that involve a mix
of feelings and ideational approaches

BINET KAMAT TEST FINDINGS

• Mental Age: 88 months

• I.Q.: 46 moderate level of intellectual impairment

Disability: 75%

Test Impression: On the basis of brief clinical history, developmental history, clinical
observation and psychological test findings it can be concluded that patient has
moderate level of intellectual impairment at present.

DIAGNOSTIC FORMULATION:

Points in Favour: Long history of substance use (injections, drugs, alcohol, tobacco,
marijuana).

Cognitive impairment and repetitive questioning.

Abusive behaviour towards his wife.

Lack of trustworthiness with money.

Social isolation, staying mostly at home.

Points in Against: No specific past psychiatric or medical history mentioned.

Lack of detailed family history or genetic predisposition to mental illness.

PROGNOSIS: The prognosis appears poor without significant intervention, given the
deterioration of cognitive function and social relationships. However, prognosis may improve
with appropriate treatment and support.

DIFFERENTIAL DIAGNOSIS:

Substance-Induced Cognitive Disorder.

Possible Neurocognitive Disorder due to Substance Use.

Major Depressive Disorder with Cognitive Impairment.

Potential Delirium or Psychosis related to substance use

MANAGEMENT PLAN:

Immediate psychiatric evaluation and possible detoxification.

Cognitive assessment to determine the extent of impairment.

Counseling and support for the wife and family.

Development of a structured treatment plan, possibly including medication to address

cognitive symptoms and behavioral therapy.

Social support to address isolation and improve interpersonal relationships.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288
 Sri Aurobindo Medical College and University, Indore, M.P.
Department of Clinical Psychology

CASE HISTORY No.: 29

IPD No.: 896098

SOCIO-DEMOGRAPHIC DETAILS:

Name: T G

Age: 20

Gender: Female

Education: 12TH

Occupation: House Wife

Marital Status: Married

Socio-economic Status: Lower

Locality: Urban

Referred By: Department of Psychiatry

Informant: Family

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “the patient wasn’t speaking anything’

Informant: “sir bhari hots hai”

“hawa mai aa gyi thi”

“dath bandh kar liye the bol nhi pari thi”

“2-3 din khan nhi khaya tha toh chamch se zabardasti pilaya tha”

“jhadfuk krwane leke gye the toh dar gyi thi”

HISTORY OF PRESENT ILLNESS (HOPI):

A one-year-old female was brought to the OPD by her family. She was born full-term
through a normal delivery with a normal birth weight and cry. Her developmental milestones
were achieved on time. The family mentioned that she gets scared easily. After her brother
scolded her for excessive mobile phone use, she became frightened. One day, she clenched
her teeth and was unable to open her mouth, leading her to go without eating for 3-4 days.
The family had to force her to drink using a spoon. Believing that she was under the influence
of some "bad air," they took her to a pandit for a ritual, which only caused her to become
more scared.

Onset: The problem began suddenly after the child was scolded by her brother for excessive
mobile phone use.
Course: The condition has had an acute onset, with specific episodes of intense fear leading
to physical symptoms such as clenching her teeth.

Progress of illness: fluctuating

Precipitating Factors: The immediate trigger for the current problem was being scolded by
her brother for using the mobile phone too much.

Predisposing Factors: The child's predisposition to fearfulness might be influenced by her

age, environmental factors, and possibly her overall health and diet.

Perpetuating Factors: The lack of proper understanding and potentially supportive responses
from the family, such as taking her to a pandit for a ritual, may be worsening or maintaining
her symptoms.

Protective Factors: N/A

Negative History:- no history suggestive of head injury

PAST MEDICAL HISTORY: N/A

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY:
PERSONAL HISTORY:

Birth and Early Development: She was born full-term through a normal delivery with a
normal birth weight and cry. Her developmental milestones were achieved on time

Childhood History: her childhood was difficult has there was lack of resources

Education and Schooling History: she completed her 12th

Occupation History: house wife

Menstrual History: at the age of 14

Marital History: she got married when she was 19

Sexual History: her sexual life is normal

PRE-MORBID PERSONALITY:

Social Relations: lack of support because of which she didn’t ad positive relation

Intellectual Activities, Hobbies and Use of Leisure time: N/A

Pre-dominant Mood of patient: The child appears to be fearful and anxious, particularly in
response to being reprimanded.

Character:

 Attitude towards Self: low self esteem

 Attitude to work or responsibility: N/A
 Interpersonal relationships: negative
 Moral and religious attitudes and standards: she visits temple daily

Habits:

Normal eating and sleeping habit

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: she came in with general apperiance

Psycho-Motor Activity: heightened during episodes of fear or anxiety.

Speech: developed

Mood and Affect: anxious, with a fearful affect.

Thought:

 Stream: disrupted during episodes of fear.

 Form: N/A
 Possession: N/A
 Content: The content of her thoughts may include fear and anxiety, particularly
related to being scolded and the rituals performed.

Perception: The child may perceive certain situations, such as being scolded or undergoing
rituals, as threatening, leading to her symptoms.

Cognition: Cognitive functions, such as memory and attention, are not specifically
mentioned but may be impacted by her anxiety.

Judgment: impaired during episodes of intense fear.

Insight: Insight into her condition is likely limited, especially given her young age and the
family's beliefs.

IMPRESSION: Dissociative Disorder

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment dissociative episode

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
4- Rorschach- ink blot test
5- Sentence Completion test
6- Thematic Apperception test

Clinical Observation and test behaviour: The patient appeared well-dressed and exhibited
orientation to time, place, and date. Her speech was normal, but capturing her attention
proved challenging. She maintained a guarded demeanour, making it difficult to extract
information from her. Additionally, she did not sustain eye contact for the necessary duration.
Furthermore, the patient consistently engaged in circular or repetitive speech patterns
RORSACHACH
Structural Summary:

Location Features Determinants Contents Approach

Zf= 13 Single H=1 I = D.Dd.Dd

ZSum=49.5 M= 1 (H) =0 II = Dd.D.Dd
ZEst = 41.5 FM =2 Hd = 2 III = D.Dd.Dd
m=0 (Hd)=0 IV =D.Dd.D.Dd.D
W=1 FC = 0 Hx = 0 V=W
D = 14 CF = 2 A= 2 VI =Dd.D.Dd
Dd = 12 C=1 Ad =2 VII = Dd,D
S=1 Cn=0 (Ad)=0 VIII = D.Dd.D
DQ FC’=0 An=3 IX = Dd
+=8 C’F=0 Art=3 X = D.D.D.D.Dd
O =8 C’=0 Ay=0
V =9 FT=4 BT=2
V/+ =4 TF=0 Cg=0
T=0 CL=2
Blends=0 FV=0 Ex=0
VF=0 Fd=0
V=0 Fi=0 Special scores
FY=0 Ge=0 LVL1 LVL2
YF=3 Hh=2 DV=0 2
Y=4 Ls=2 INC=2 0
Fr=0 Na=2 DR=0 0
Rf=0 Sc=0 FAB=0 0
FD=0 Sx=0 ALOG=4
F=12 Xy=0 CON=1
Id=6 Raw Sum 6=9
(A)=0 Wgtd=35

AB= 4 PHR=3
AG=1 GHR =3
Form Quality COP=0 MOR = 0
FQx MQual W + D=15 CP=0 PER=0
+=0 +=0 +=0 PSV=8
o=4 o=1 o=4
u = 25 u=0 u = 11
-=0 -=0 -=0
 Ratios, percentages and Derivations

R = 29 L = 0.75
EB = 1:3.5 EA =4.5 EBPer =3.5 FC: CF + C =0:3 AG =1
eb = 2:11 es = 13 D = -8.5 Pure C =1 a: p = 1:2
Adj es = -7.5 Adj D = -3 SumC’: WsumC=0:3.5 Human Cont. =3
P=4
FM =2 SUMC’=0 WSUMC=3.5 Afr =0.45 Pure H =1
m=0 SUMT=4 S=1 2AB+(ART+Ay) =7
SUMY=0 Blends: R =0:29 ISOLATED R=0.41
CP =0 Zd= 8

a: p =1:2 Sum6 = 9 XA% =1 Zf=13 3r + (2)/R = 0.41

Ma: Mp =0:1 Lv2 = 2 WDA% = 1 W:D: Dd = 1:14:12 Fr + rF = 0
Mor = 0 Wsum6 =35 X-%= 0 W:M = 1:1
M- =0 X+% =0.13 DQ+ = 8 MOR =0
Xu% = 0.86 DQv= 9 H: (H) + Hd + (Hd) = 1:2

PTI = 2 DEPI = 5 CDI = 4 S-CON= 4. HVI=no OBS=no

INTERPRETATION
There was a total of 29 responses on 10 cards, rendering the protocol valid for interpretation.
Findings suggests that the person is highly vulnerable to loss of control and becoming
disorganized under stress.
The person has limited available resources.
Findings suggests that the stress is having greater impact on emotion. Experiences of anxiety,
tension and discomfort for which the person has little or no exploitation are quite probable.
Scorings suggests an overload state exists in which the individual is experiencing more
internal demands than he or she can respond to easily or effectively. As a result, the capacity
for control is lessened, decisions or behaviours may not be well thought through or
implemented, and a proclivity for impulsiveness exists.
Findings suggests that patient often complain about recurring bouts of depression, moodiness,
tension, or anxiety, however many do not report periodic episodes involving negative
emotional experiences.
Scores also suggest a state of emotional disarray is likely to exist. However, the affective
problem usually is secondary to a more pervasive difficulty in creating and maintaining
effective and rewarding interpersonal relationship.
Findings suggest that it can be assumed that very little decision making occurs that is not
markedly influenced by emotion.
Scores also suggest that in most instances emotion will play a very limited role in decision
making activity. It is also likely that most emotional displays will be closely modulated and
more intuitive trial and error approaches to problem solving or decision making will be
avoided, even though such an approach might be much more effective.
Findings suggests that the person uses intellectualization as a major defensive tactic in
situations that are perceived as affectively stressful. People such as this tend to become more
vulnerable to disorganization during intense emotional experiences because the tactic
becomes less effective as the magnitude of affective stimuli increases.

Scores suggest that the individual is less stringent about modulating emotional discharges
than are most adults. People such as this tend to be more obvious or intense in expressing
feelings that the average individual.
Findings usually indicates the presence of an overincoprative style. Overincoperation is an
enduring trait-like style that includes the exertion of more effort in scanning activities.
Overincorporaters apparently want to avoid being careless and this motivates them to invest
more effort than maybe necessary to scan the feature of a situation.
Scores indicates that the quality of processing activity becomes very flawed and less mature
forms of processing results. This is most common for person who are in some sort of
noticeable psychological disarray.
Findings suggests that the individual makes a special effort to ensure that mediation is
appropriate for the situation.
Findings tells us that the pattern of ideational activity among ambitent, related to decision
making, is not very predictable. This is true even though situations requiring a decision may
be very similar.
Scores indicates that it is probable that the person tends to react quickly to reduce the
irritations created by the intrusion of peripheral thoughts.
Findings indicates that the person has a distinct tendency to defensively substitute more often
than do most people. This can be very effective defensive strategy and should not be
considered as a liability unless other evidence indicates that the person is markedly dependent
on others.
Responses clearly seems to Evidence significantly disturbed thinking, the recent behavioural
history of the person will probably contain some confirming information about this. if the
behavioural history fails to provide this confirmation the possibility of some form of
exaggeration or malingering of symptoms should be considered.
Findings also suggest that it is almost certain that some unusual body concern or
preoccupation is present.
Scores also indicates that the person is probably less socially mature than might be expected.
This is the type of individual who is limited in social skills and is disposed to experience
frequent difficulties when interacting with the environment, especially the interpersonal
sphere.

Findings indicates the presence of strong unfulfilled needs for closeness. In most case, the
increased intensity of these natural yearning will be reactive, having been provoked by a
recent emotional loss.
Scores suggest that the person is more socially isolated

Test Impression:
The findings suggest that the individual is highly vulnerable to loss of control and
disorganization under stress, with limited available resources. The impact of stress on
emotions is pronounced, leading to experiences of anxiety, tension, and discomfort. Scores
indicate an overload state, resulting in impulsive decisions and diminished capacity for
control.

The person often complains of recurring bouts of depression, moodiness, tension, or anxiety,
although periodic episodes involving negative emotional experiences may not be reported.
Emotional disarray is likely, secondary to difficulties in creating and maintaining effective
interpersonal relationships.

Decision making is markedly influenced by emotion, yet emotional displays are closely
modulated. The use of intellectualization as a defense mechanism is observed during
affectively stressful situations, but it becomes less effective with intense emotional stimuli.
The individual tends to be less stringent in modulating emotional discharges, displaying more
obvious or intense feelings than the average person. An overincoprative style is present,
characterized by an enduring trait-like effort to scan activities thoroughly, potentially leading
to flawed processing activity.

The pattern of ideational activity related to decision-making is unpredictable, and the person
reacts quickly to reduce irritations from peripheral thoughts. Defensive substitution is a
common strategy, which may be effective unless dependence on others is evident.

Responses indicate significantly disturbed thinking, with the behavioural history likely
containing confirming information. Unusual body concerns or preoccupations are almost
certain, and the person appears to be less socially mature, experiencing difficulties in social
interactions. Strong unfulfilled needs for closeness, likely reactive to recent emotional loss,
contribute to increased social isolation.

Sentence completion Test (SCT)

The patient's inability to finish the sentence completion test renders it invalid

Thematic Apperception Test

Integrated Summary of the test-

 Main Theme: The main theme of the story revolves around Achievement,

succorance, nurturance, affiliation, fear, distrust and rejection.

 Main Hero: The main hero of the story was a female and can be identified with
self.

 Intellectual level: The narrative plots lacked structure, authenticity, and completion,

appearing disorganized and insufficient. The stories lacked proper organization and

exhibited a level of imagination that was below satisfactory, indicating a less

advanced intellectual capability in the subject.

 Emotional maturity: The patient’s emotional maturity is not in accordance to her age
 and sex.

 Personal adjustment: Her personal adjustment is not satisfactory.

 Social Adjustment: She has inadequate interpersonal relations with family members.

 Needs of the Hero: The dominant needs of the hero are need for succorance,

rejection, nurturance, affiliation and achievement.

 Significant conflicts: Conflicts relating to interpersonal conflict, emotionality.

 Nature of Anxieties: The main nature of anxieties was lack of support, emotional

understanding and interpersonal conflict.

 Main Defenses: significant defence was found to be rationalization and projection.

1. Ego-structure: Fear, anxiety, distrust and sadness are present in her inner dynamics.

2. Basic personality: The dominant traits of the hero are emotionality, distrust and

anxiety ridden.

Test Impression:

The narratives suggest variability in the patient's ability to identify with the hero, being

adequate in some instances and inadequate in others. The self-portrayal reflects a sense of

fear, anxiety, and stress within interpersonal relationships. Certain stories indicate the

patient's needs for nurturing, support, love, and stable healthy relationships. Achievement

also emerges as needs in some narratives, while others reveal elements of affiliation and

rejection.

In the 5th card, the story indicates a need for aggression, while in the 7th card, the need for

sex is projected. Overall, the stories point to conflicts in interpersonal relationships and

highlight
the patient's need for support and family-related anxieties. The findings suggest a desire for

love, protection, and a pursuit of a peaceful life. The overarching themes centre around

anxiety, low self-esteem, a confused sense of self-worth, and challenges in relationships. The

primary sources of anxiety appear to be a lack of support and emotional understanding. The

dominant characteristics of the hero in these narratives are characterized by anxiety and

emotional struggles.

Final report:

The findings suggest that the individual is highly vulnerable to stress-induced loss of control
and disorganization, with limited resources. Emotionally, they experience pronounced
impacts of stress, leading to anxiety, tension, and discomfort, often resulting in impulsive
decisions and reduced control. Recurring bouts of depression, moodiness, and anxiety are
reported, hinting at emotional disarray and difficulties in interpersonal relationships.
Decision-making is emotionally influenced, with displays closely modulated, and the use of
intellectualization as a defence mechanism observed.

The individual tends to display more intense emotions and employs an overincoprative style,
scanning activities thoroughly, potentially leading to flawed processing. Ideational activity
related to decision-making is unpredictable, with quick reactions to reduce peripheral
irritations. Defensive substitution is common, and significantly disturbed thinking is noted in
responses. Unusual body concerns, social immaturity, and difficulties in social interactions
are apparent, with strong unfulfilled needs for closeness contributing to increased social
isolation.

The narratives reveal variability in the ability to identify with the hero, reflecting fear,
anxiety, and stress in interpersonal relationships. The need for nurturing, support, love, and
stable relationships is evident, along with conflicting themes of achievement, affiliation, and
rejection. The 5th card suggests a need for aggression, while the 7th card projects a need for
sex, both highlighting conflicts in interpersonal relationships. Overall, the stories indicate a
desire for support, family-related anxieties, love, protection, and a pursuit of a peaceful life.
Dominant themes include anxiety, low self-esteem, a confused sense of self-worth, and
challenges in relationships, rooted in a lack of support and emotional understanding. The hero
in these narratives is characterized by anxiety and emotional struggles.

DIAGNOSTIC FORMULATION:
Points in Favour: Sudden onset of symptoms following a scolding.

Increased fearfulness, particularly in response to specific situations.

Cultural practices may be exacerbating her anxiety.

Points in Against: No previous history of psychiatric or medical issues.

Normal development and milestones achieved.

PROGNOSIS: The prognosis may be guarded, depending on the family's understanding and
response to her condition. If supportive measures are taken and the child is given a safe
environment, her condition may improve. However, if the family continues to rely on
spiritual rituals that exacerbate her fear, her symptoms may persist or worsen.

DIFFERENTIAL DIAGNOSIS: Acute stress disorder

Separation anxiety disorder

Somatic symptom disorder

Pediatric anxiety disorder

MANAGEMENT PLAN:

Psychoeducation: Educate the family about the potential psychological causes of her
symptoms and the importance of reducing stressors.

Behavioral Interventions: Introduce techniques to help the child manage fear, such as
relaxation exercises or gradual exposure to feared situations.

Family Counseling: Encourage the family to provide a supportive environment and avoid
punitive or frightening practices.

Monitoring: Regular follow-ups to assess the child’s progress and adjust the management
plan as needed.

Assessment done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma
M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.: 30

OPD No.: 14482973

SOCIO-DEMOGRAPHIC DETAILS:

Name: P S

Age: 32

Gender: Male
Education: N/A

Occupation: N/A

Marital Status: N/A

Socio-economic Status: Lower

Locality: rural

Referred By: MGM Medical Collage

Informant: Niece

Reliability of Information: Unsatisfactory

Adequacy of Information: Inadequate

CHIEF COMPLAINTS:

Patient: “patient didn’say anything”

Informant: “kuch bhi smj nhi padhti hai”

“toilet training nhi nhi hai”

HISTORY OF PRESENT ILLNESS (HOPI):

A 32-year-old male patient was brought to the OPD by his niece. According to the
information provided, he was born full-term. The patient has not received toilet training and
lacks comprehension of basic concepts.

Onset: insidious

Course: continuous

Progress of illness: deteriorating

Precipitating Factors: Lack of comprehension and toilet training.

Predisposing Factors: N/A

Perpetuating Factors N/A

Protective Factors: N/A

Negative History:N/A

PAST MEDICAL HISTORY: N/A

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: N/A

PERSONAL HISTORY:

Birth and Early Development: According to the information provided, he was born full-
term. The patient has not received toilet training and lacks comprehension of basic concepts.

Childhood History: he had a difficult childhood as he had no training

Education and Schooling History: he didn’t go to school

Occupation History: N/A

PRE-MORBID PERSONALITY:
Social Relations: he is introvert

Intellectual Activities, Hobbies and Use of Leisure time: N/A

Pre-dominant Mood of patient: N/A

Character:

 Attitude towards Self: N/A

 Attitude to work or responsibility: N/A
 Interpersonal relationships: negative
 Moral and religious attitudes and standards:N/A

Habits: normal eating and sleeping pattern

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: came in with general apperiance

Psycho-Motor Activity: N/A

Speech: Normal

Mood and Affect: N/A

Thought:

 Stream: N/A
 Form: N/A
 Possession:N/A
 Content: N/A

Perception: N/A

Cognition: N/A

Judgment: N/A

Insight: N/A

IMPRESSION: Profound Intellectual Impairment

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment lack of comprehension

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
29- Vineland Social Maturity Scale
30- Seguin Form Bord Test
31- Binet Kamat Test (BKT)

Behavior Observation during Testing-

The patient presented with a general appearance, but faced challenges in maintaining eye
contact and spoke with a subdued tone. Furthermore, the patient seemed disoriented, lacking
awareness of time, place, and date. It was also challenging to capture and sustain the patient's
attention for the necessary duration.

Clinical Note:
We couldn't perform VSMS as the patient came in with his niece, who didn't have all the
information. Instead, we tried to conduct SFBT but he couldn’t perform that either.

 Vineland Social Maturity Scale

Inadequate information.

 Seguin Form Board Test

Couldn’t perform

 Binet Kamat Test

• . Mental Age: 34 months (2years 8 months)
• I.Q.: 18 profound level of intellectual impairment

Disability: 100%
 Test Impression: On the basis of brief clinical history, developmental history, clinical
observation and psychological test findings it can be concluded that patient has
profound level of intellectual impairment at present.

Clinical Note:
We couldn't perform VSMS as the patient came in with his niece, who didn't have all the
information. Instead, we tried to conduct SFBT but he couldn’t perform that either.

DIAGNOSTIC FORMULATION:

Points in Favour: The patient, a 32-year-old male, was born full-term.

He has not received toilet training.

He lacks comprehension of basic concepts.

Points in Against: No specific medical or psychiatric history provided to support an

alternative diagnosis.

No precipitating factors or significant family history that might contribute to the current
condition.

PROGNOSIS: Prognosis is likely guarded given the static progress of the illness and lack of
basic developmental milestones such as toilet training and comprehension.

DIFFERENTIAL DIAGNOSIS: Intellectual Disability

Autism Spectrum Disorder

Neurodevelopmental Disorder

MANAGEMENT PLAN:

Conduct a comprehensive neuropsychological evaluation to assess cognitive function.

Implement a structured behavioral therapy program to address toilet training and daily living
skills.
Provide support and education for the family to improve understanding and care strategies.

Consider referral to a specialist in developmental disorders for further assessment and

management.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.: 31

OPD No.: 1435366

SOCIO-DEMOGRAPHIC DETAILS:

Name: L S

Age: 24

Gender: Male
Education: KGI

Occupation: N/A

Marital Status: N/A

Socio-economic Status:

Locality: Sub-urban

Referred By: Department of Psychiatry

Informant: Family

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “the patient didn’t speak anything”

Informant: “jab papa ki death hui thi uske baad se jhatke aane shuru hue”

“ek din sari goliyan kha gaya tha”

“gale mai khar khar ki awaz aati hai”

“bachpan mai 2 bar iske upper se motor cycle nikili”

“ghumne jata hai toh ghumte he reh jata hai”

“muh pe jhatke aate hai bar bar”

HISTORY OF PRESENT ILLNESS (HOPI):

A 24-year-old male presented to the outpatient department with his family. He was born full-
term with a normal birth weight and delivery, but his birth cry was absent. He achieved his
developmental milestones on time. During childhood, he was run over by a motorcycle twice.
After his father's death, he began experiencing seizures. He has poor personal hygiene and
sometimes leaves food in his mouth without chewing. On one occasion, he took all his
medication at once. His food intake is limited by a small mouth opening, and his face exhibits
many involuntary movements.

Onset: The onset of his seizures began after his father's death.

Course: fluctuating

Progress of illness: deteriorating

Precipitating Factors: The specific event that triggered his current problems was his father's
death, which led to the onset of seizures

Predisposing Factors: The absence of a birth cry might suggest early neurological issues, but
there are no specific predisposing factors mentioned related to climate, weather, or other
environmental conditions.

Perpetuating Factors: Perpetuating factors include poor personal hygiene, difficulty with
eating (keeping food in his mouth), and the tendency to take all his medication at once. The
lack of support and potential issues related to his behavior also contribute to worsening his
condition.

Protective Factors: N/A

Negative History: - no history suggestive of head injury.

PAST MEDICAL HISTORY: medication for his seizure

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: N/A

PERSONAL HISTORY:

Birth and Early Development: He was born full-term with a normal birth weight and
delivery, but his birth cry was absent. He achieved his developmental milestones on time.

Childhood History: he has a difficult childhood as there were limited resources available

Education and Schooling History: he has only studies till class KGI

Occupation History: N/A

PRE-MORBID PERSONALITY:

Social Relations: supportive family environment

Intellectual Activities, Hobbies and Use of Leisure time: N/A

Pre-dominant Mood of patient: N/A

Character:

 Attitude towards Self: not reported

 Attitude to work or responsibility: not reported
 Interpersonal relationships: positive relation with family
 Moral and religious attitudes and standards: N/A
Habits:

Abnormal eating and normal sleep

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: the general appearance of the patient was not
appropriate and his behaviour with the examiner was not cooperative

Psycho-Motor Activity: Displays involuntary facial movements; may indicate possible

motor abnormalities.

Speech: normal

Mood and Affect: N/A

Thought:

 Stream: N/A
 Form: N/A
 Possession: N/A
 Content: N/A

Perception:

N/A

Cognition: Difficulty with eating (leaving food in mouth) and potentially with cognitive
processing.

Judgment: Poor judgment, as evidenced by taking all his medication at once.

Insight: N/A

IMPRESSION: Profound level of socio adaptive functioning and Intellectual Impairment

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment was referred for IQ Assessment

 Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
32- Vineland Social Maturity Scale (VSMS)
33- Binet Kamat Test (BKT)
Behavior Observation during Testing-
o General Appearance: - He came with his family. His general appearance
was normal.
Language and communication: - Speech is not developed.

Test Findings:
 Vineland Social Maturity Scale Social Age: 16.3 months
 Social Quotient: 6 that is profound which means he has profound level of social adaptive
functioning.
 Pattern Analysis of Vineland Social Maturity Scale (VSMS)
S.no Social Social Age Social Quotient Interpretation
Areas/Domain (Months)
89. Self Help 32 11 profound
General

90. Self Help Eating 32 11 profound

91. Self Help N/A N/A N/A

Dressing

92. Self-Direction N/A N/A N/A

93. Occupation 44 16 profound

94. Communication 10 4 profound

7. Locomotion 21.6 8 Profound

8. Socialization 44 16 profound
  Test Impression: On the basis of brief clinical history, developmental history,
clinical observation and psychological test findings it can be concluded that patient
has profound level of socio adaptive functions

 Binet Kamat Test

• . Mental Age: 22 months

• I.Q.: 8 profound level of intellectual impairment

Disability: 100%

Test Impression: On the basis of brief clinical history, developmental history, clinical
observation and psychological test findings it can be concluded that patient has
profound level of intellectual functioning at present.

DIAGNOSTIC FORMULATION:

Points in Favour: Seizures following a significant emotional trauma.

Poor personal hygiene and eating difficulties indicating possible cognitive or behavioral
issues.

Involuntary facial movements.

Points in Against: no psychiatric illeness

PROGNOSIS: deteriorating due to ongoing seizures and poor self-care.

DIFFERENTIAL DIAGNOSIS:

Neurological disorders (e.g., seizure disorders, motor abnormalities).

Possible psychiatric conditions secondary to trauma or stress.

MANAGEMENT PLAN:

Further evaluation by a neurologist for seizure management and facial involuntary

movements.
Assessment by a psychiatrist for potential cognitive or behavioral issues.

Support for improving personal hygiene and managing medication correctly.

Psychological support or therapy to address emotional impact from the father’s death.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

 Department of Clinical Psychology

CASE HISTORY No.: 32

OPD No.: 15290024

SOCIO-DEMOGRAPHIC DETAILS:

Name: D H

Age: 11

Gender: Male

Education: N/A

Occupation: N/A

Marital Status: N/A

Socio-economic Status: Lower

Locality: Urban

Referred By: Self

Informant: Family

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “patient has hearing issues

Informant:

“tez awaz sunta hai

“sirf papa bolta hai”

“asthma ka problem hai”

“2 din peti mai tha”

“bina wajha logo ko mart hai”

“bolta bhi nhi hai”

HISTORY OF PRESENT ILLNESS (HOPI):

An 11-year-old patient was brought to the OPD by his family. He was born prematurely at 8
months, weighing 1.5 kg, and had a delayed birth cry. After birth, he was placed in an
incubator for the first two days, with no feeding during that period. The patient responds only
to loud noises and can only say the word "papa." He exhibits aggressive behavior, hitting
others without any apparent reason, and has been diagnosed with asthma.

Onset: The patient's symptoms began at birth, with a delayed cry and the need for incubator
care immediately after delivery.

Course: continuous

Progress of illness: static

Precipitating Factors: N/A

Predisposing Factors: The patient was born prematurely at 8 months, with a low birth weight
of 1.5 kg, and was kept in an incubator without feeding for the first two days. These early life
factors, along with his current asthma condition, may have predisposed him to his ongoing
health challenges.

Perpetuating Factors: The patient’s aggressive behavior, such as hitting others without
reason, along with limited communication (he only says "papa"), are perpetuating factors that
may be influenced by a lack of supportive relationships and the inability to express himself
effectively.

Protective Factors N/A

Negative History:-no history suggestive of use of harmful substance

PAST MEDICAL HISTORY: The patient was born prematurely at 8 months, weighing 1.5
kg, and required incubator care for the first two days of life. He has asthma.
PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: not reported

PERSONAL HISTORY:
Birth and Early Development: He was born prematurely at 8 months, weighing 1.5 kg, and
had a delayed birth cry. After birth, he was placed in an incubator for the first two days, with
no feeding during that period.

Childhood History: he had difficult childhood as he couldn’t hear or speak

Education and Schooling History: N/A

Occupation History: N/A

PRE-MORBID PERSONALITY:

Social Relations: The patient has limited social interactions. He only responds to loud voices
and can only say "papa." His interactions are mostly aggressive, as he tends to hit people
without apparent reason

Intellectual Activities, Hobbies and Use of Leisure time: N/A

Pre-dominant Mood of patient: The patient's mood appears to be irritable, given his
aggressive tendencies and limited communication abilities.

Character:

 Attitude towards Self: The patient shows limited self-awareness, as indicated by his
inability to communicate effectively and respond only to loud sounds.
 Attitude to work or responsibility: N/A
 Interpersonal relationships: The patient’s interpersonal relationships are strained
and aggressive, with no meaningful social connections evident.
 Moral and religious attitudes and standards: N/A
Habits:

Normal eating and sleeping habits

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: came in with general appearance and was not
cooperative with examiner

Psycho-Motor Activity: increased psycho-motor activity, possibly linked to his aggressive

behavior.

Speech: His speech is extremely limited, as he only says the word "papa" and does not
respond to normal sounds, only to loud voices

Mood and Affect: The patient's mood appears irritable, with a flat or blunted affect, given
his limited speech and aggressive behavior.

Thought:

 Stream: disorganized, as he has difficulty communicating and only reacts to loud

sounds.
 Form: underdeveloped or impaired, considering his limited speech capabilities.
 Possession: N/A
 Content: underlying distress or frustration, contributing to his aggressive actions, but
specific thought content is not detailed.

Perception: The patient’s perception seems to be impaired, as he only responds to loud

sounds and has limited verbal communication.

Cognition: There appears to be cognitive impairment, as evidenced by his inability to

communicate effectively and his limited response to environmental stimuli.
 Judgment: Judgment is likely impaired, as the patient’s aggressive actions and limited
communication suggest difficulty in making appropriate decisions.

Insight: Insight is likely poor, as the patient does not demonstrate awareness of his condition
or the consequences of his actions.

IMPRESSION: Above average level of socio adaptive functioning

PSYCHOLOGICAL ASSESMENT:
Rationale for Psychological Assessment was referred for IQ test

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
34- Vineland Social Maturity Scale (VSMS)
35- Seguin Form Board

Behavior Observation during Testing-

The patient appeared generally well. Establishing eye contact was easy, and rapport was
quickly built. The patient demonstrated good comprehension.

Test Findings:
 Vineland Social Maturity Scale Social Age: 155 months (12years and 9 months)
Social Quotient: that is 117 which means he has above average level of social adaptive
functioning.

Pattern Analysis of Vineland Social Maturity Scale (VSMS)

S.no Social Social Age Social Quotient Interpretation
Areas/Domain (Months)
 95. Self Help 52 40 moderate level
General
96. Self Help 116 88 Below average
Eating level
97. Self Help 156 118 Above Average
Dressing level
98. Self-Direction 168 127 Superior
99. Occupation 180 136 Genius
100. Communication 144 109 average level

Locomotion 116 88 Below average

7.
level
8. Socialization 168 126 superior level

Test Interpretation: On the basis of brief clinical history, developmental history,

clinical observation and psychological test findings it can be concluded that patient
has above average level of socio adaptive functioning.

DIAGNOSTIC FORMULATION:

Points in Favour: Premature birth at 8 months with low birth weight (1.5 kg)

Delayed birth cry and early incubation without feeding

Limited verbal communication (only says "papa")

Aggressive behavior, such as hitting others

Responds only to loud sounds

Diagnosed with asthma

Points in Against: Lack of detailed family history or additional medical conditions that could
explain the symptoms
No history of head injury or substance use

PROGNOSIS: The prognosis may be guarded, considering the patient's developmental

delays, limited communication, and aggressive behavior. Early intervention and specialized
care may be necessary to improve his quality of life.

DIFFERENTIAL DIAGNOSIS: Developmental disorder (e.g., Autism Spectrum Disorder)

Cognitive impairment

Sensory processing disorder

Behavioral disorder

MANAGEMENT PLAN:

Comprehensive developmental and psychological assessment

Referral to a pediatric neurologist and developmental specialist

Speech therapy and occupational therapy

Behavioral intervention to address aggression

Monitoring and management of asthma

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma
M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology
 CASE HISTORY No.: 33

OPD No.: 14600112

SOCIO-DEMOGRAPHIC DETAILS:

Name: T C

Age: 9

Gender: Male

Education: N/A

Occupation: N/A

Marital Statu : N/A

Socio-economic Status: Middle

Locality: rural

Referred By: MGM Medical Collage

Informant: Parents

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “mai toh logo ko mar deta hu

“koi mujhe kuch bolta hai toh mko ghusse aati hai”

“gaon ke baccho ke sth jake cig pee hai maine’

Informant: “kisi ki bhi nhi sunta hai”

“kisi ko bhi mar deta hai”

“kis se bhi dar nhi lgta hai”

“kahi bhi aag lge deta hai”

“12 kele kha leta hai ohr bhi bhook lgti hai”

“school bhejte hai toh baccho ko mar ke aa jata hai”

“koi school mai admission nhi dera hasi”

HISTORY OF PRESENT ILLNESS (HOPI):

A 9-year-old male was brought to the OPD by his parents. He was born at full term via a
normal delivery with a present birth cry. During his childhood, he contracted TB but did not
receive proper treatment. According to his parents, the patient is very stubborn. He has an
unusual appetite, able to eat 12 bananas and still feel hungry. He exhibits aggressive
behavior, such as beating people and throwing stones. He has a habit of setting things on fire
and has smoked with his friends. If anyone tries to reprimand him, he responds by beating
them. He disrupts schools by entering random classrooms and preventing other students from
studying. The patient also takes money from his father's pocket to buy chips, often spending
the entire amount, such as 500 rupees, on chips and consuming them all at once.

Onset: The onset of the patient's behavioral issues seems to be related to his early childhood,
particularly after he contracted TB and did not receive proper treatment.

Course: continuous

Progress of illness: static

Precipitating Factors: A specific precipitating factor could be the lack of proper treatment for
TB during childhood, which may have contributed to the onset of his behavioral issues.

Predisposing Factors: The patient's early health challenges, such as untreated TB, along with
his age and diet, may have predisposed him to his current condition.

Perpetuating Factors: Perpetuating factors include the patient's aggressive and disruptive
behavior, such as beating people, throwing stones, and setting things on fire. The lack of
effective intervention and possibly unsupportive relationships at home may also be
contributing to the persistence of his issues.

Protective Factors: N/A

Negative History:-no history suggestive of head injury

PAST MEDICAL HISTORY: The patient contracted TB in childhood but did not receive
proper treatment for it.

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: N/A

PERSONAL HISTORY:

Birth and Early Development: He was born at full term via a normal delivery with a
present birth cry. During his childhood, he contracted TB but did not receive proper
treatment.

Childhood History: he had a difficult childhood as he didn’t receive treatment for tb

Education and Schooling History: he didn’t go to school

Occupation History: N/A

Substance Use History: he has smoked with his friends

 PRE-MORBID PERSONALITY:

Social Relations: The patient exhibits aggressive and disruptive behavior, including beating
people, throwing stones, and setting things on fire, indicating poor social relationships. He
also enters random schools and disrupts classes, preventing other students from studying.

Intellectual Activities, Hobbies and Use of Leisure time: N/A

Pre-dominant Mood of patient: The patient seems to exhibit a predominantly aggressive

and defiant mood, as evidenced by his violent actions and disregard for rules or social norms.

Character:

 Attitude towards Self: The patient shows a lack of self-regulation and impulse
control, as seen in his overeating, smoking, and aggressive behavior.
 Attitude to work or responsibility: The patient demonstrates a disregard for
responsibility, as he disrupts other students' ability to study and engages in reckless
behavior.
 Interpersonal relationships: The patient has poor interpersonal relationships,
characterized by aggression and violence towards others.
 Moral and religious attitudes and standards: The patient’s behavior, such as
stealing money and smoking, suggests a disregard for moral standards.

Habits:

Abnormal eating habits

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: he came in with typical appearance

Psycho-Motor Activity: increased, given his tendency to engage in physically aggressive

acts and disruptive behaviour.

Speech: normal speech

Mood and Affect: exhibits an irritable and aggressive mood with a corresponding affect.

Thought:

 Stream: disorganized or impulsive, leading to erratic behavior.

 Form: fragmented or chaotic, reflecting his inability to adhere to social norms.
  Possession: N/A
 Content: revolve around aggressive and disruptive actions, with a potential disregard
for consequences.

Perception: N/A

Cognition: impaired, as suggested by his lack of judgment and impulsivity in decision-

making, such as spending all his money on chips.

Judgment: judgment is poor, as evidenced by his reckless behavior and inability to foresee
the consequences of his actions.

Insight: The patient likely lacks insight into the severity and impact of his behavior on
himself and others.

IMPRESSION: Conduct Disorder

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment behavioural issues

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
36- Binet Kamat Test (BKT)

Behavior Observation during Testing-

The patient presented with a general appearance, but faced challenges in maintaining eye
contact and spoke with a subdued tone. Furthermore, the patient seemed disoriented, lacking
awareness of time and date. It was also challenging to capture and sustain the patient's
attention for the necessary duration.

 Binet Kamat Test

• . Mental Age: 66months (5year 5month)
• I.Q.: 61 mild level of intellectual impairment

Disability: 50%
 Test Impression: On the basis of brief clinical history, developmental history,
clinical observation and psychological test findings it can be concluded that patient
has mild level of intellectual impairment at present.

DIAGNOSTIC FORMULATION:

Points in Favour:

 History of untreated TB in childhood.

 Exhibits aggressive and disruptive behavior.
 Impulsivity and lack of judgment.
 Substance use (smoking).

Points in Against: No specific mention of developmental delays or cognitive impairments,

though behavioral issues are present.

PROGNOSIS: The prognosis is guarded, given the patient's current behavior and lack of
insight. Early intervention and appropriate treatment could potentially improve his condition.

DIFFERENTIAL DIAGNOSIS:

 Oppositional Defiant Disorder (ODD)

 Attention-Deficit/Hyperactivity Disorder (ADHD)
 Possible neurological sequelae of untreated TB

MANAGEMENT PLAN:

1. Comprehensive psychiatric evaluation to assess the underlying causes of the patient’s

behavior.
2. Behavioral therapy to address aggression and impulsivity.
3. Family counseling to improve home dynamics and support.
4. Nutritional and dietary counseling to manage excessive eating.
5. Close monitoring for any substance use and guidance on cessation.
6. Coordination with school authorities to manage disruptive behavior in educational
settings.
Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288
 Sri Aurobindo Medical College and University, Indore, M.P.
Department of Clinical Psychology

CASE HISTORY No.: 34

OPD No.: 14602237

SOCIO-DEMOGRAPHIC DETAILS:

Name: A G

Age: 4.5

Gender: Male

Education: N/A

Occupation: N/A

Marital Status: N/A

Socio-economic Status: Lower middle

Locality: Urban

Referred By: Department of Audio and Speech

Informant: Parents

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “the patient doesn’t speak”

Informant: “bolta nhi hai bachpan se”

“thoda chlta hai phr godi godi krta hai”

“bht he zda ghusse krta hai”

HISTORY OF PRESENT ILLNESS (HOPI):

A 4-year-old male patient visited the OPD with his parents. He was born 5-6 days past the
due date, with a normal birth weight and an immediate birth cry. The parents reported that he
does not speak and exhibits significant behavioral issues, including stubbornness.

Onset: insidious

Course: continuous

Progress of illness: static

Precipitating Factors: N/A

Predisposing Factors: N/A

Perpetuating Factors: N/A

Protective Factors: N/A

Negative History: -no history suggestive of head injury

PAST MEDICAL HISTORY: N/A

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: N/A

PERSONAL HISTORY:
Birth and Early Development: He was born 5-6 days past the due date, with a normal birth
weight and an immediate birth cry.

Childhood History: difficult childhood as the patient couldn’t speak

Education and Schooling History: N/A

Occupation History: N/A

PRE-MORBID PERSONALITY:

Social Relations: The patient interacts primarily with family members. His relationships with
friends, relatives, and society are minimal due to his young age and behavioral challenges.

Intellectual Activities, Hobbies and Use of Leisure time: N/A

Pre-dominant Mood of patient: N/A

Character:

 Attitude towards Self: N/A

 Attitude to work or responsibility: N/A
 Interpersonal relationships: N/A
 Moral and religious attitudes and standards:N/A

Habits: normal eating and sleeping habits

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: came in with general appearance

Psycho-Motor Activity: N/A

Speech: Not Developed

Mood and Affect: N/A

Thought:

 Stream: N/A
 Form: N/A
 Possession:N/A
 Content: N/A

Perception: N/A
 Cognition: underdeveloped for his age, particularly in speech and social interactions.

Judgment: N/A

Insight: N/A

IMPRESSION: Below Average level of socioadaptive functioning

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment speech delay

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
37- Vineland Social Maturity Scale (VSMS)
38- Developmental Screening Test (DST)

Chief Complaints-

2. “Bolta nahi hai

3. Autism hai

Behavior Observation during Testing-

The overall appearance of the patient seemed typical. However, he exhibited challenges in
maintaining eye contact and was not easily responsive to attempts to capture his attention.
The patient displayed impatience and prevented his father from speaking. Establishing
rapport with the patient proved to be challenging.

Test Findings:
 Vineland Social Maturity Scale Social Age: 45 months
Social Quotient: that is 83 which means he has below average level of social adaptive
functioning.
Pattern Analysis of Vineland Social Maturity Scale (VSMS)
S.no Social Social Age Social Quotient Interpretation
Areas/Domain (Months)
 101. Self Help 32 59 Mild level
General

102. Self Help 32 59 Mild level

Eating

103. Self Help 60 111 Above Average

Dressing

104. Self-Direction N/A N/A N/A

105. Occupation 64 119 Above average

106. Communication 40 74 Borderline level

Locomotion 52 96 Average level

7.

8. Socialization 44 85 Below average

level


Test Interpretation: 83 social quotient that indicates that the patient has
below average level of social adaptive functioning
Developmental Screening Test

 Developmental Age: 40 months

• Developmental Quotient: 74 is mild level of developmental behaviour
functioning

 Test Interpretation: 74 developmental quotient that indicates tha the patient has
mild level of developmental functioning.

 Test Impression: On the basis of brief clinical history, developmental history,

clinical observation and psychological test findings it can be concluded that patient
has below average level of socio adaptive and intellectual functioning at present.
DIAGNOSTIC FORMULATION:
Points in Favour:

 Speech delay and behavioral issues are evident.

 No significant medical or psychiatric history reported.
 Family reports stubborn behavior.

Points in Against:

No clear underlying condition or diagnosis yet identified.

PROGNOSIS: The prognosis is uncertain at this stage. Further assessment and possibly
early intervention may be needed to address the speech and behavioral issues.

DIFFERENTIAL DIAGNOSIS:

 Developmental Delay
 Autism Spectrum Disorder
 Behavioral Disorders

MANAGEMENT PLAN:

 Comprehensive developmental assessment.

 Speech therapy referral.
 Behavioral intervention strategies.
 Follow-up for monitoring progress.

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288
 Sri Aurobindo Medical College and University, Indore, M.P.
Department of Clinical Psychology

CASE HISTORY No.: 35

OPD No.:14658060

SOCIO-DEMOGRAPHIC DETAILS:

Name: A C

Age: 9

Gender: Male

Education: 1st

Occupation: Student

Marital Status: N/A

Socio-economic Status: Middle

Locality: Urban

Referred By: Department of Paediatric

Informant: Father

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “mann nhi lgta hai kisi bhi kam hai”

Informant:” dimag histir nhi hai”

“marta hai aut katta hai”

“apni he dhun mai retha hai”

“smoking krta hai”

“ghar mai paise rkhe hote hai toh utha ke chle jata hai”
“kuch yaad nhi retha hai”

“chappal bhi bhul jata hai kahi bhi”

HISTORY OF PRESENT ILLNESS (HOPI):

A 9-year-old male patient presented to the OPD. He was born full-term at nine months, and
his developmental milestones were typical. However, the patient exhibits significant
behavioral issues, including a lack of concentration, chasing after people to hit and bite them,
and taking money from home to spend indiscriminately. He has a poor memory, even
forgetting directions and his slippers when he goes out. Additionally, he has a history of
smoking and continues to wet the bed.

Onset: insidious

Course: continuous

Progress of illness: fluctuating

Precipitating Factors: N/A

Predisposing Factors: N/A

Perpetuating Factors: N/A

Protective Factors: N/A

Negative History:- no history suggestive of head injury

PAST MEDICAL HISTORY: N/A

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: N/A

PERSONAL HISTORY:

Birth and Early Development: He was born full-term at nine months, and his
developmental milestones were typical

Childhood History: he had a difficult childhood as there were lack of available resources

Education and Schooling History: 1st

Occupation History: student

Substance Use History:

He smokes

PRE-MORBID PERSONALITY:

Social Relations: he doesn’t have positive social relations

Intellectual Activities, Hobbies and Use of Leisure time: N/A

Pre-dominant Mood of patient: N/A

Character:

 Attitude towards Self: N/A

 Attitude to work or responsibility:N/A
 Interpersonal relationships: N/A
 Moral and religious attitudes and standards: N/A

Habits: normal eating and sleeping habits

 MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: he came in with general appearance.

Psycho-Motor Activity: N/A

Speech:N/A

Mood and Affect:N/A

Thought:

 Stream: N/A
 Form: N/A
 Possession:N/A
 Content: N/A

Perception: N/A

Cognition: N/A

Judgment: N/A

Insight:N/A

IMPRESSION: mild level of socio adaptive functioning

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment behavioural issues

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
39- Vineland Social Maturity Scale (VSMS)
40- Binet Kamat Test (BKT)

Behavior Observation during Testing-

The overall appearance of the patient seemed typical. However, he exhibited challenges in
maintaining eye contact and was not easily responsive to attempts to capture his attention.
The patient displayed impatience. Establishing rapport with the patient proved to be
challenging. The patient wasn’t oriented to time, date, day, week or month.
 Test Findings:
 Vineland Social Maturity Scale Social Age: 64 months
Social Quotient: that is 67 which means he has mild level of social adaptive functioning.
Pattern Analysis of Vineland Social Maturity Scale (VSMS)
S.no Social Social Age Social Quotient Interpretation
Areas/Domain (Months)
107. Self Help 52 54 Mild level
General

108. Self Help 88 92 Average

Eating
109. Self Help 84 88 Below Average
Dressing
110. Self-Direction N/A N/A N/A

111. Occupation 100 104 average

112. Communication 80 83 Below average

Locomotion 52 54 Mild
7.

8. Socialization 68 71 Borderline

 Test Interpretation: 67 social quotient that indicates that the patient has mild
level of social adaptive functioning

Binet Kamat Test

• . Mental Age: 66months (5year 5month)
• I.Q.: 69 mild level of intellectual impairment

Disability: 50%
 Test Interpretation: 69 IQ indicates that the patient has mild level of intellectual
impairment.

DIAGNOSTIC FORMULATION:

Points in Favour:

 Full-term birth with typical developmental milestones.

 Significant behavioral issues, including aggression (chasing people to hit and bite).
 Poor concentration and memory (forgetting directions, slippers).
 Risky behaviors such as smoking and taking money from home.
 Bedwetting, which may indicate underlying psychological or neurological issues.

Points in Against:

 No history of developmental delays or significant head injuries.

 No clear precipitating factors identified.
 Lack of specific information on any medical or psychiatric conditions.

PROGNOSIS: The prognosis is uncertain but may be guarded due to the fluctuating nature
of the symptoms and the presence of multiple concerning behaviors, including aggression and
poor memory. Early intervention and consistent management could potentially improve
outcomes.

DIFFERENTIAL DIAGNOSIS:

 Attention-Deficit/Hyperactivity Disorder (ADHD)

 Conduct Disorder
 Oppositional Defiant Disorder (ODD)
 Neurodevelopmental Disorder
 Early-onset Psychosis
 Reactive Attachment Disorder (if there is a history of trauma or neglect)

MANAGEMENT PLAN: Behavioral Therapy: Implement structured behavioral

interventions to address aggression and poor concentration.

 Cognitive Assessment: Conduct a thorough cognitive and psychological evaluation to

better understand the underlying issues.
 Parental Guidance: Provide support and guidance to the parents on managing the child’s
behavior at home.
 Medication: Consider the use of medications if ADHD or another neurodevelopmental
disorder is diagnosed.
 Monitoring: Regular follow-ups to monitor the patient’s progress and adjust the
management plan as needed.
 Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.: 36

OPD No.: 15674589

SOCIO-DEMOGRAPHIC DETAILS:

Name: H J

Age: 26

Gender: Female

Education: Diploma in Graphic Design

Occupation: Graphic Designer

Marital Status: N/A

Socio-economic Status: Upper Middle

Locality: Sub-urban

Referred By: Self

Informant: Friend

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “ghr walo se love marrie ki bat krni hai but vo amnn nhi rahe hai”

“boyfriend force krra h ki jaldi jaldi bt kro”

“boyfirnd ne time limit dedi ki agar 1 month mai bt nhi ki toh chd dega”

“jab pms hota hai tb uthne ka bhi mann nhi krta hai”

Informant:

“jab pms hita h tb aggressive bhi ho jati hai”

HISTORY OF PRESENT ILLNESS (HOPI):

A 26-year-old female came into the OPD with her boyfriend. She was born full-term with a
normal weight and reached all developmental milestones on time. She reported that during
PMS, she is unable to function, spending the entire day in bed and not engaging in any
activities, including cooking. She comes from a strict family and recently tried to discuss her
desire to marry her boyfriend with her parents. However, she's finding it difficult to convince
them. Her boyfriend is pressuring her to gain their approval within a month. She is fearful
that if she fails, he will leave her, leaving her feeling alone.

Onset: insidious

Course: continuous

Progress of illness: fluctuating

Precipitating Factors: The current issue with her boyfriend pressuring her to convince her
parents for marriage within a month has heightened her anxiety and worsened her symptoms.

Predisposing Factors: Strict family upbringing may have contributed to her current mental
health challenges. Additionally, societal expectations and her strict environment could be
influencing her current state.

Perpetuating Factors: Lack of supportive relationships within her family, pressure from her
boyfriend, and poor coping mechanisms are perpetuating her condition.
Protective Factors: N/A

Negative History:- no history suggestive of Depression

PAST MEDICAL HISTORY: N/A

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY:N/A

PERSONAL HISTORY:

Birth and Early Development: She was born full-term with a normal weight and reached all
developmental milestones on time

Childhood History: she had a difficult childhood as there was lack of support from her
family

Education and Schooling History: she completed her diploma in graphic designing

Occupation History: she is a graphic designer

Menstrual History: when she was 11

Sexual History: active sexual life

Substance Use History: occasional alcohol

 PRE-MORBID PERSONALITY:

Social Relations: she has many positive social relations

Intellectual Activities, Hobbies and Use of Leisure time: she likes to draw and read

Pre-dominant Mood of patient: cheerful

Character:

 Attitude towards Self: low self esteem

 Attitude to work or responsibility: careless
 Interpersonal relationships: positive
 Moral and religious attitudes and standards: not significant

Habits:

Normal eating and sleeping habits

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: she came in with general appearance

Psycho-Motor Activity: N/A

Speech:N/A

Mood and Affect: Anxious

Thought:

 Stream: N/A
 Form: N/A
 Possession:N/A
 Content: N/A

Perception:N/A

Cognition: Normal

Judgment: sound

Insight: N/A

IMPRESSION: Separation Anxiety Disorder

 PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment her anxious nature

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
1-Rorschach Ink Blot Test

Clinical Observation and test behaviour:

Her general appearance was neat and well kempt. Touch with surrounding was present. Eye
contact was maintained properly. Attitude towards the examiner was cooperative. Rapport
was established easily. Motor behaviour was appropriate. Her speech was normal. Thought
stream was normal, but thought content was limited. Attention was easily aroused and
managed to be sustained for the required period. she was well oriented towards time, place,
day, date, month and year. she was able to understand and follow the test instructions which
were given by the examiner

Rorschach Ink Blot Test

Structural Summary:

Location Features Determinants Contents Approach

Zf= 11 Single H=0 I = W.D.W

ZSum=37.5 M= 4 (H) =1 II = D.Dd.Dd
ZEst = 34.5 FM =4 Hd = 2 III = D.D.D.D.D

m=2 (Hd)=1 IV = W.Dd

W=6 FC = 0 Hx = 1 V=W

D = 15 CF = 1 A= 9 VI =Dd.Dd.D
Dd = 7 C=2 Ad =4 VII = D.Dd
S=2 Cn=0 (Ad)=1 VIII = W.D.D.D.Dd
DQ FC’=0 An=6 IX = D
+=7 C’F=0 Art=2 X = D.D.Dd.Dd.W
O =20 C’=0 Ay=0
V =3 FT=0 BT=0
V/+ =0 TF=0 Cg=0
 T=0 CL=0
FV=0 Ex=0
VF=0 Fd=0
Blends:0 V=0 Fi=0 Special scores
FY=0 Ge=0 LVL1 LVL2
YF=1 Hh=0 DV=0 0
Y=0 Ls=0 INC=0 2
Fr=0 Na=1 DR=0 2
Rf=0 Sc=2 FAB= 0 0
FD=2 Sx=0 ALOG=1
F=14 Xy=1 CON=0
Id=1 Raw Sum 6=5
(A)=0 Wgtd=25
(2)=7
AB= 1 PHR= 4
AG= 0 GHR = 1
Form Quality COP= 0 MOR = 1
FQx MQual W + D=21 CP= 0 PER=0
+ = 00 +=0 +=0 PSV=1
o = 10 o=0 o = 10
u = 12 u=2 u=5
-=7 -=2 -=4
N=1 N=0 N=1

Ratios, percentages and Derivations

R = 30 L =0.46
EB = 4:4 EA =8 EBPer =0 FC: CF + C = 0:3 AG = 0
eb = 6:1 es = 7 D=1 Pure C = 2
Adj es = -1 Adj D = 9 SumC’: WsumC =0:4 Human Cont. =5
P=3
FM = 4 WSUMC=4 Afr = 0.36 Pure H = 0
m=2 SUMT=0 SUMC’=0 S=2 2AB+(ART+Ay) =2
SUMY=1 Blends: R =0:30 ISOLATED R=0.06
CP = 0 Zd=3

a: p =4:6 Sum6 = 5 XA% = 0.73 Zf= 11 3r + (2)/R = 0.23

Ma: Mp =1:3 Lv2 = 4 WDA% = 0.71 W:D: Dd = 6:15:7 Fr + rF = 0
Mor = 1 Wsum6 =25 X-%= 0.23 W:M = 6:4 SumV = 0
M- = 2 X+% = 0.33 DQ+ = 7
Xu% = 0.4 DQv= 3 H: (H) + Hd + (Hd) = 0:4
PTI = 2 DEPI = 2 CDI = 4 S-CON= . 2 HVI= no OBS= no

Interpretation

Findings signifies that the person has a sturdier tolerance for stress than do most.

Findings suggest that the person is experiencing some distress.

Scores also suggests that it can be assumed that the psychological consequences of the stress
tend to be diffuse, impacting on both thinking and emotion.

Findings also indicates a marked tendencies to avoid emotional stimuli. People such as this
usually are quite uncomfortable when dealing with emotion. As a result, they often become
much more socially constrained or even isolated.

Scores indicates some potentially serious modulation problems. People such as this are often
overly intense in their emotional displays and frequently convey impression of impulsiveness.

Scores suggest that it is likely that the processing efforts and strategies used are similar to that
of most people.

Findings indicates that the person is striving to accomplish more than maybe reasonable in
light of current functional capacities.

Scores also suggests that there is presence of overincooperative style.

Findings suggest that at times the person has some difficulty shifting attention.

Findings suggest that it can be assumed that the quality of processing usually is adequate.

Scores reflect a significant mediational impairment.

Findings suggest that there may be some pervasive tendencies to mediastinal disfunction.

Scores suggests that it represent a more deliberately defensive distortion of reality.

Findings also suggests that the pattern of ideational activity among ambitents, related to
decision making is not very predictable. Findings suggest that it can be assumed that the
person is using an ideational style involving instances will occur in which feeling will
contribute significantly to decision. Scores suggest that it can be presumed that the ideational
sets and values of the person are reasonably well fixed and would be somewhat difficult to
alter. Findings suggest that it can be surmised that internal need state are causing the person
to experience a substantial level of peripheral mental activity. Scores suggest that the person
has a distinct tendency to defensively substitute fantasy to reality in stressful situation more
often than do most people. Findings signific that thinking is likely to be seriously disturbed.
Scores suggest that there is a possibility of some form of exaggeration or malingering of
symptoms should be considered. Findings suggest that it is very likely that thinking is
peculiar or disturbed.

Test Impression

In simpler terms, the findings indicate that the person seems to handle stress better than
average but is still experiencing some distress. They may struggle with emotional stimuli,
leading to social discomfort or isolation. They might also display intense emotions and
impulsiveness, possibly having difficulty in moderating their reactions. Moreover, they seem
to push themselves too hard despite their current abilities, and they might have trouble
shifting their attention at times. Their thinking processes are generally adequate, but there
might be some significant impairments in how they process information, possibly leading to
distorted perceptions of reality.

Decision-making patterns are unpredictable, with feelings often playing a significant role.
Their values and thought patterns are quite fixed and might be challenging to change. They
may experience a lot of mental activity due to internal needs, sometimes relying on fantasy
rather than reality in stressful situations.

Overall, their thinking appears to be disturbed

DIAGNOSTIC FORMULATION:

Points in Favour:  History of head injuries and seizures.

 Delayed developmental milestones.
 Aggressive behavior and cognitive impairments.

Points in Against:  Lack of clear organic causes in some cases.

 Some patients achieved early milestones like walking and talking within normal ranges,
which may complicate the diagnosis.

PROGNOSIS: The prognosis is guarded due to the combination of early developmental

delays, ongoing cognitive impairments, and the continuous nature of the symptoms.

DIFFERENTIAL DIAGNOSIS:

Generalise Anxiety Disorder

Major Depressive Disorder

MANAGEMENT PLAN:

Cognitive Behavioural Therapy

Motivational Enhancement

Assessment Done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.: 37

OPD No.: 15053164

SOCIO-DEMOGRAPHIC DETAILS:
Name: V J

Age: 3

Gender: Male

Education: N/A

Occupation: N/A

Marital Status:N/A

Socio-economic Status: Middle

Locality: Sub-urban

Referred By: Department of Audio and Speech

Informant: Family

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “patient couldn’t speak”

Informant: “sunai bht kam deta hai”

“bolti bhi nhi hai”

HISTORY OF PRESENT ILLNESS (HOPI):

A 3-year-old female patient was brought to the OPD by her parents. She was born at full term
(9 months) via C-section, with a birth weight of 3 kg and a present birth cry. While she began
walking on time, her speech has not yet developed, and her hearing is significantly impaired.
There is a family history of similar conditions, as her aunts' daughters are also unable to
speak or hear.

Onset: The patient has had delayed speech development and significant hearing impairment
from early childhood.

Course: continuous

Progress of illness: static

Precipitating Factors: There is no specific event or trigger identified as causing the onset of
the current problem.

Predisposing Factors: The patient's condition may be influenced by genetic factors, as

evidenced by the family history of hearing and speech impairments.

Perpetuating Factors: The patient's condition may be perpetuated by the lack of effective
intervention or supportive measures at home or in her environment.

Protective Factors Protective factors include early diagnosis and potential access to medical
care that could help manage or mitigate the condition.

Negative History: - no history suggestive of head injury.

-no history suggestive of exposure to harmful substance.

PAST MEDICAL HISTORY: N/A

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: The patient's family history is significant, as her aunt's daughters also
have speech and hearing impairments.
(With Genogram)

PERSONAL HISTORY:

Birth and Early Development: She was born at full term (9 months) via C-section, with a
birth weight of 3 kg and a present birth cry. While she began walking on time, her speech has
not yet developed, and her hearing is significantly impaired.

Childhood History: she had a difficult childhood as she can not speak or hear.

Education and Schooling History: she didn’t go to school

Occupation History: N/A

PRE-MORBID PERSONALITY:

Social Relations: The patient’s social interactions, particularly within her family, may be
limited due to her hearing and speech impairments.
Intellectual Activities, Hobbies and Use of Leisure time: Given her young age and her
developmental delays, the patient’s engagement in intellectual activities and hobbies might be
minimal.

Pre-dominant Mood of patient: she exhibits frustration or withdrawal due to her

communication challenges.

Character:

 Attitude towards Self: N/A

 Attitude to work or responsibility: N/A
 Interpersonal relationships: patient’s ability to form interpersonal relationships may
be impacted by her speech and hearing impairments.
 Moral and religious attitudes and standards: N/A
Habits:

Her eating and sleeping habits are normal

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: The patient likely appears developmentally

appropriate for her age, but with noticeable communication difficulties.

Psycho-Motor Activity: No specific abnormalities in psychomotor activity are mentioned

Speech: The patient has not yet developed speech, which is a significant area of concern.

Mood and Affect: signs of frustration or withdrawal due to her communication challenges.

Thought:
  Stream: N/A
 Form: Undeveloped
 Possession: N/A
 Content: N/A
Perception: N/A

Cognition: No abnormalities

Judgment: N/A

Insight: N/A

IMPRESSION: Average level of Socio Adaptive Functioning

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment behaviour issue

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
41- Vineland Social Maturity Scale (VSMS)
42- Seguin Form Board

Behavior Observation during Testing-

The overall appearance of the patient seemed typical. However, he exhibited challenges in
maintaining eye contact and was not easily responsive to attempts to capture his attention.
The patient displayed impatience and prevented his mother from speaking. Establishing
rapport with the patient proved to be challenging.
Test Findings:
 Seguin Form Board
The patient couldn’t perform the test.
 Vineland Social Maturity Scale Social Age: 42 months
Social Quotient: that is 92 which means she has average level of social adaptive
functioning.

Pattern Analysis of Vineland Social Maturity Scale (VSMS)

S.no Social Social Age Social Quotient Interpretation
Areas/Domain (Months)
113. Self Help 52 113 Above average
General level

114. Self Help 32 70 borderline level

Eating

115. Self Help 56 122 Above average

Dressing level

116. Self-Direction N/A N/A N/A

117. Occupation 32 70 borderline level

118. Communication 40 100 average level

40 100 average level

0 7. Locomotion

8. Socialization 44 96 average level

 Test Interpretation: 92 social quotient that indicates that the patient has

average level of social adaptive functioning at present.

 DIAGNOSTIC FORMULATION:

Points in Favour: Family history of speech and hearing impairments.

Delayed speech development and significant hearing loss.

Normal birth and developmental milestones except for communication issues.

Points in Against: Lack of information about other potential contributing factors or

environmental influences.

No detailed assessment of cognitive development.

PROGNOSIS: The prognosis may depend on early intervention, including hearing aids,
speech therapy, and potential genetic counselling.

DIFFERENTIAL DIAGNOSIS: Congenital hearing loss with associated speech delay.

Genetic disorders related to hearing and speech.

Developmental language disorder secondary to hearing impairment.

MANAGEMENT PLAN:

Immediate audiological assessment to determine the extent of hearing loss.

Referral to a speech therapist for evaluation and intervention.

Genetic counselling to explore the family history and assess risks for other family members.

Continuous monitoring of cognitive and developmental milestones to identify any further

delays or issues.
Family education and support to ensure a conducive environment for the patient’s
development.

Assessment done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

 Department of Clinical Psychology

CASE HISTORY No.: 38

IPD No.: 939516

SOCIO-DEMOGRAPHIC DETAILS:

Name: A V

Age: 3

Gender: Male

Education: N/A

Occupation: N/A

Marital Status:N/A

Socio-economic Status: Middle

Locality: Sub-urban

Referred By: Department of Audio and Speech

Informant: Family

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “patient couldn’t speak”

Informant: “sunai bht kam deta hai”

“bolti bhi nhi hai”

HISTORY OF PRESENT ILLNESS (HOPI):

A 3-year-old female patient was brought to the OPD by her parents. She was born at full term
(9 months) via C-section, with a birth weight of 3 kg and a present birth cry. While she began
walking on time, her speech has not yet developed, and her hearing is significantly impaired.
There is a family history of similar conditions, as her aunts' daughters are also unable to
speak or hear.

Onset: The patient has had delayed speech development and significant hearing impairment
from early childhood.

Course: continuous

Progress of illness: static

Precipitating Factors: There is no specific event or trigger identified as causing the onset of
the current problem.

Predisposing Factors: The patient's condition may be influenced by genetic factors, as

evidenced by the family history of hearing and speech impairments.

Perpetuating Factors: The patient's condition may be perpetuated by the lack of effective
intervention or supportive measures at home or in her environment.

Protective Factors Protective factors include early diagnosis and potential access to medical
care that could help manage or mitigate the condition.

Negative History: - no history suggestive of head injury.

-no history suggestive of exposure to harmful substance.

PAST MEDICAL HISTORY: N/A

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY: The patient's family history is significant, as her aunt's daughters also
have speech and hearing impairments.
(With Genogram)

PERSONAL HISTORY:

Birth and Early Development: She was born at full term (9 months) via C-section, with a
birth weight of 3 kg and a present birth cry. While she began walking on time, her speech has
not yet developed, and her hearing is significantly impaired.

Childhood History: she had a difficult childhood as she can not speak or hear.

Education and Schooling History: she didn’t go to school

Occupation History: N/A

PRE-MORBID PERSONALITY:

Social Relations: The patient’s social interactions, particularly within her family, may be
limited due to her hearing and speech impairments.
Intellectual Activities, Hobbies and Use of Leisure time: Given her young age and her
developmental delays, the patient’s engagement in intellectual activities and hobbies might be
minimal.

Pre-dominant Mood of patient: she exhibits frustration or withdrawal due to her

communication challenges.

Character:

 Attitude towards Self: N/A

 Attitude to work or responsibility: N/A
 Interpersonal relationships: patient’s ability to form interpersonal relationships may
be impacted by her speech and hearing impairments.
 Moral and religious attitudes and standards: N/A

Habits:

Her eating and sleeping habits are normal

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: The patient likely appears developmentally

appropriate for her age, but with noticeable communication difficulties.

Psycho-Motor Activity: No specific abnormalities in psychomotor activity are mentioned

Speech: The patient has not yet developed speech, which is a significant area of concern.

Mood and Affect: signs of frustration or withdrawal due to her communication challenges.

Thought:
  Stream: N/A
 Form: Undeveloped
 Possession: N/A
 Content: N/A

Perception: N/A

Cognition: No abnormalities

Judgment: N/A

Insight: N/A

IMPRESSION: Average level of Socio Adaptive Functioning

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment was referred for IQ Assessment

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
43- Vineland Social Maturity Scale (VSMS)
44- Developmental Screening Test (DST)

Behavior Observation during Testing-

The overall appearance of the patient seemed typical. However, he exhibited challenges in
maintaining eye contact and was not easily responsive to attempts to capture his attention.
The patient displayed impatience and prevented his mother from speaking. Establishing
rapport with the patient proved to be challenging.
 Test Findings:
 Vineland Social Maturity Scale Social Age: 49 months
Social Quotient: that is 100 which means he has average level of social adaptive
functioning.

Pattern Analysis of Vineland Social Maturity Scale (VSMS)

S.no Social Social Age Social Quotient Interpretation
Areas/Domain (Months)
119. Self Help 32 88 Below average
General level
120. Self Help 32 88 Below Average
Eating level

121. Self Help 56 155 Genuis

Dressing
122. Self-Direction N/A N/A N/A
123. Occupation 44 122 superior level
124. Communication 22 77 borderline level

Locomotion 52 144 Genius

7.

8. Socialization 40 111 Above Average

level

 Test Interpretation: 100 social quotient that indicates that the patient has
average level of social adaptive functioning

Developmental Screening Test

Developmental Age: 19 months
Developmental Quotient: 53 is mild level of developmental behaviour functioning
  Test Interpretation: 53 developmental quotient that indicates tha the patient has
moderate level of developmental functioning.

DIAGNOSTIC FORMULATION:

Points in Favour: Family history of speech and hearing impairments.

Delayed speech development and significant hearing loss.

Normal birth and developmental milestones except for communication issues.

Points in Against: Lack of information about other potential contributing factors or

environmental influences.

No detailed assessment of cognitive development.

PROGNOSIS: The prognosis may depend on early intervention, including hearing aids,
speech therapy, and potential genetic counselling.

DIFFERENTIAL DIAGNOSIS: Congenital hearing loss with associated speech delay.

Genetic disorders related to hearing and speech.

Developmental language disorder secondary to hearing impairment.

MANAGEMENT PLAN:

Immediate audiological assessment to determine the extent of hearing loss.

Referral to a speech therapist for evaluation and intervention.

Genetic counselling to explore the family history and assess risks for other family members.

Continuous monitoring of cognitive and developmental milestones to identify any further

delays or issues.
Family education and support to ensure a conducive environment for the patient’s
development.

Assessment done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

 Department of Clinical Psychology

CASE HISTORY No.: 39

IPD No.: 932623

SOCIO-DEMOGRAPHIC DETAILS:

Name: P H

Age: 17

Gender: Male

Education: 10TH

Occupation: Student

Marital Status: N/A

Socio-economic Status: Upper Middle

Locality: Urban

Referred By: Department of paediatric

Informant: Family

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “mera diamg nhi chlta”

“mai kuch nhi kar pata”

15-16 saal bht hote hai jene ke liye”

“mai marna chatha hu “

“meko kisi kisi ki nhi padi”

Informant: “bht aggressive hai”

“kahi pe bhi marne lg jata hai”

“iski demands puri na kro toh bht zda aggressive ho jata hai”

“bate nhi s,jta hai”

“chote bacche jesa behave krta hai”

“urine and stool control mai nhi hai”

HISTORY OF PRESENT ILLNESS (HOPI):

A 15-year-old patient was brought to the OPD by his brother. He was born full-term and
reached his developmental milestones on time. From an early age, he exhibited aggressive
behaviour, such as biting. In 2015, his parents separated, and although he was an above-
average student, he was frequently forced to study and physically punished. The patient was
stubborn, often making demands, and would throw tantrums if his needs were not met.

His heart rate increases to 170 bpm when he becomes agitated. Last year, his father suffered a
stroke, which traumatized the patient. This trauma was compounded when he overheard his
close aunt speaking negatively about him, which left him shocked. Following these events, he
lost hope, began feeling worthless, and believed he was incapable of doing anything right.
His aggressive behaviour worsened, leading him to physically attack his brother and father.

During a visit to the market with his mother, he lay down on raw cement and covered
himself. When his mother tried to stop him, he responded by throwing stones at her. After his
father's stroke, his academic performance declined drastically, dropping from once scoring
90% to getting only 2-3 marks. On one occasion, after experiencing an upset stomach, his
mother instructed him to clean up in the washroom, but instead, he soiled the entire house and
walked in the mess like a young child might.
The patient has made multiple suicide attempts, which he claims are for attention, but these
attempts have become more frequent. His attention-seeking behaviour is escalating, as he
calls relatives at any time, asking them to visit him because he is "unwell." His demands have
also increased, and when they are not met, he becomes aggressive, often beating his brother.
The patient urine and stool are not in his control. He has undergone treatment for
schizophrenia and got 6-7 ECT

Onset: The onset of the patient's issues began last year following two significant events: his
father's stroke and overhearing his aunt speak negatively about him.

Course: Since these events, the patient has exhibited worsening symptoms, including
increased aggression, declining academic performance, and escalating attention-seeking
behaviors.

Progress of illness: deteriorating

Precipitating Factors: the trauma from his father's stroke and the psychological impact of
hearing his aunt criticize him

Predisposing Factors: Potential predisposing factors include the long-standing stress from his
parents' separation and being subjected to physical punishment and academic pressure from
an early age.

Perpetuating Factors: The ongoing lack of a supportive family environment, particularly the
strained relationships with his parents, as well as his declining academic performance, which
may contribute to his worsening behaviour and mental health.

Protective Factors: There appear to be limited protective factors in his current environment,
given the absence of a supportive family dynamic and the ongoing behavioural and emotional
challenges.

Negative History: - no history suggestive of hallucination

-no history suggestive of head injury.

-no history suggestive of delusions

PAST MEDICAL HISTORY: not reported

PAST PSYCHIATRIC HISTORY: he has undergone treatment for schizophrenia and got
6-7 ECT

FAMILY HISTORY: The family history includes parental separation in 2015 and the
father's stroke last year. The family environment is characterized by a lack of support and
strained relationships.

PERSONAL HISTORY:

Birth and Early Development: He was born full-term and reached his developmental
milestones on time

Childhood History: he had a traumatic childhood as his parents got separated and there was
lack of family support.

Education and Schooling History: he studied till class 10th

Occupation History: not significant

 PRE-MORBID PERSONALITY:

Social Relations: The patient had strained relationships within his family, particularly after
his parents' separation in 2015. He has had ongoing conflicts, especially with his brother and
father. His interactions with others, including relatives, have been negatively affected by his
aggressive behaviour and attention-seeking tendencies.

Intellectual Activities, Hobbies and Use of Leisure time: like to watch movies

Pre-dominant Mood of patient: The patient has displayed a mood characterized by

frustration, feelings of worthlessness, and increasing aggression.

Character:

 Attitude towards Self: The patient has developed a negative self-image, believing he
is "good for nothing" and incapable of achieving anything.
 Attitude to work or responsibility: His attitude toward academic responsibilities has
deteriorated, as evidenced by his significant decline in academic performance.
 Interpersonal relationships: The patient struggles with maintaining positive
interpersonal relationships, particularly within his family. His interactions have
become increasingly aggressive and conflictual.
 Moral and religious attitudes and standards: he is very interested in mythologies

Habits:

His eating habits are normal but his sleep is disturbed

MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: the patient came in with general appearance first he
was not very cooperative with the examiner later he developed a bond of trust with the
examiner

Psycho-Motor Activity: Increased psycho-motor activity is evident in his aggressive

outbursts, physical altercations, and tantrums.

Speech: normal speech

Mood and Affect: The patient's mood is predominantly aggressive, frustrated, and marked
by feelings of worthlessness. His affect is likely to be labile and reactive, especially in
response to perceived slights or unmet demands.

Thought:

 Stream: Likely pressured and disorganized during episodes of anger.

 Form: Thought processes may be disorganized, particularly when agitated.
 Possession: no abnormalities
 Content: Thoughts of worthlessness, frustration, and aggressive impulses. Suicidal
ideation is present, primarily as a means of seeking attention.

Perception: No perceptual disturbances, such as hallucinations or delusions, have been

reported.

Cognition: There is a significant decline in cognitive functioning, particularly in academic

performance and problem-solving abilities.

Judgment: Impaired judgment is evident in his inability to respond appropriately to

situations, such as his regressive behaviour and aggressive actions.

Insight: The patient appears to have limited insight into his condition, acknowledging his
suicide attempts as attention-seeking but not recognizing the underlying emotional distress

IMPRESSION: Depression F32A

 PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment was referred

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
1- Rorschach Ink Blot Test
Behavior Observation during Testing-
The patient presented with a generally normal appearance. He maintained eye contact and

rapport was easily established. He was oriented to the year, month, and time, but not to the

specific date. Throughout the testing, the patient continuously smiled. He required a

significant amount of time to complete the test, and prompts were needed to assist him.

Structural Summary:

Location Features Determinants Contents Approach

Zf= 11 Single H=0 I = Dd. W.W

ZSum=34 M= 0 (H) =0 II = D.W.W
ZEst = 34.5 FM =0 Hd = 3 III = D.D

m=0 (Hd)=1 IV = Dd.W.Dd.Dd

W=6 FC = 0 Hx = 0 V=W

D = 15 CF = 0 A= 0 VI =D.Dd
Dd = 5 C=0 Ad =0 VII = W.D.D
S=1 Cn=0 (Ad)=0 VIII = D.Dd.D
DQ FC’=0 An=11 IX = D.D.D
+=4 C’F=0 Art=3 X = D.D.D
O =20 C’=0 Ay=1
V =2 FT=0 BT=1
V/+=1 TF=0 Cg=0
T=0 CL=0
FV=0 Ex=0
VF=0 Fd=0
Blends:FC.FY V=0 Fi=0 Special scores
FY=0 Ge=0 LVL1 LVL2
YF=0 Hh=0 DV=0 0
Y=0 Ls=1 INC=0 0
 Fr=0 Na=0 DR= 1 1
Rf=0 Sc=1 FAB= 0 0
FD=2 Sx=0 ALOG=0
F=24 Xy=0 CON=0
Id=1 Raw Sum 6= 1
(A)=0 Wgtd=
(2)=8
AB= 0 PHR=4
AG=0 GHR =0
Form Quality COP=0 MOR = 0
FQx MQual W + D=21 CP=0 PER=1
+=0 +=0 +=0 PSV=0
o=4 o=0 o=0
u = 15 u=0 u=3
-=8 -=0 -=1

Ratios, percentages and Derivation

R = 27 L = 0.88
EB = 0:1 EA =1 EBPer = 0 FC: CF + C =1:0 AG = 0
eb = 0 es = 0 D=1 Pure C = 0 a: p = 0
Adj es =1 Adj D =0 SumC’: WsumC =0:1 Human Cont. =4
P=1
FM = 0 WSUMC=1 Afr = 0.5 Pure H =0
m=0 SUMT=0 SUMC’=0 S=1 2AB+(ART+Ay) =4
SUMY=1 Blends: R =1:27 ISOLATED R=0.07
CP = 0 Zd=-0.5

a: p =0 Sum6 = 2 XA% = 0.70 Zf= 11 3r + (2)/R =0.29

Ma: Mp =0 Lv2 = 1 WDA% = 0.14 W:D: Dd =6:15:5 Fr + rF = 0
Mor = 0 Wsum6 =9 X-%= 0.29 W:M = 6:0 SumV = 0
M- = 0 X+% = 0.14 DQ+ = 4 MOR = 0
Xu% = 0.55 DQv= 2 H: (H) + Hd + (Hd) =0:4

PTI = 0 DEPI = 3 CDI = 4 S-CON= 6. HVI= NO OBS= NO

Interpretation
Findings suggests that the personality organization of the person is somewhat less mature

than might be expected. This tends to create a vulnerability for problems in coping with the

requirements of everyday living. Such difficulties usually are manifest in the interpersonal

sphere and can easily contribute to problems in control when they occur.

Scores suggests more limited available scores.

Finding indicates that need states are not being experienced in typical ways, or that they are

being acted on more rapidly than is the case for most people.

Scores suggests that the impact of the situational stress will probably range from mild to

moderate and there is presence of some psychological disruption.

Finding indicates that the individual seems as willing as most others with their particular

coping style (or age in the instance of children) ally toned stimuli. Generally, this is not a sig

to process and become involved with emotionnificant finding but, if the person tends to have

persistent difficulties with the modulation or control of emotion it may indicate a naive lack

of awareness concerning those problems. Usually, when emotional stimuli are processed

some response or exchange is required.

Scores indicates that it can be assumed that the person controls or modulates emotional

discharge about as much as most adults.

Findings suggest that t suggests that the psychology of the person is less complex than

expected. This finding is most common among those whose psychological organization is

marked by immaturity. People such as this often-manifest behavioral difficulties when they

are confronted with complex emotional situations.

Scores suggest that It can be assumed that there is only a very mild increase in psychological

complexity because of the stress conditions.

Findings indicates that the person is striving to accomplish more than may be reasonable in

light of current functional capacities. If this tendency occurs in everyday behaviours, the

probability of failure to achieve objectives is increased, and the consequent impact of those

failures can often include the experience of frustration.

Scores suggest that it can be a significant liability because under incorporation creates a

potential for faulty translation of cues that are present, leading to less effective pat- terns of

behaviour. Under incorporation usually can be corrected rather easily by cognitive re-

structuring methods that emphasize delay and thorough scanning.

Scores signals the likelihood of a serious meditational impairment.

Score suggests that a preoccupation is provoking mediational dysfunction. In most instances,

the nature of the preoccupation will be reflected by the content category(s), but in some cases

the pre- occupation will only be clarified when the responses are read during the review of

data concerning self-perception.

Finding suggests that there is a substantial likelihood of more atypical or even inappropriate

behaviours than might be expected. The prone- ness toward unconventional behaviours is

most likely to be induced by forms of mediational dysfunction and problems in reality

testing. The interpretation should stress this and avoid mention of any distinctive orientation

toward individuality.

Scores suggest that it is probable that the person tends to react quickly to reduce the

irritations created by the intrusions of peripheral thoughts.

Findings suggest that the individual may adopt or accept a distorted form of conceptual

thinking that serves to deny the true impact of a situation.

Scores also suggest that it is reasonable to assume that the individual's estimate of personal

worth tends to be negative. Such individuals regard themselves less favourably when

compared to others. This characteristic is often a precursor to depression.

Findings suggest that it is almost certain that some unusual body concern or preoccupation is

present.

Test Impression

The personality organization of the individual appears less mature than expected, leading to

difficulties in coping with everyday living requirements, especially in interpersonal

interactions. This immaturity may contribute to problems in control and can create

vulnerability to stress. The individual's scores suggest limited available coping resources and

that their needs are either not experienced typically or acted upon too rapidly. Situational

stress is likely to cause mild to moderate psychological disruption.

DIAGNOSTIC FORMULATION:

Points in Favour: History of aggression and behavioural issues since childhood.

Significant decline in academic performance.

Recent traumatic experiences, including his father’s stroke and familial criticism.

Multiple suicidal attempts with increasing frequency.

Escalating attention-seeking behaviors and demands.

Points in Against: Lack of detailed information on other potential psychiatric symptoms, such
as anxiety or psychosis.

No prior history of psychiatric diagnosis before the onset of current symptoms.

PROGNOSIS: The prognosis is guarded, with the potential for improvement if appropriate
interventions are implemented, including addressing family dynamics, managing aggression,
and improving emotional regulation.

DIFFERENTIAL DIAGNOSIS:

Mood Disorder (e.g., Major Depressive Disorder with features of irritability and aggression)

Conduct Disorder

Oppositional Defiant Disorder

Adjustment Disorder with disturbance of conduct

Trauma-Related Disorder (e.g., PTSD)

MANAGEMENT PLAN:

Immediate Interventions: Assess and manage suicidal risk, potentially involving

hospitalization if necessary.

Behavioural Therapy: Focus on managing aggression, improving impulse control, and

developing healthier coping mechanisms.

Family Therapy: Address family dynamics and provide support to improve communication
and reduce conflict.

Academic Support: Tailor an academic plan that accommodates the patient's current
emotional and cognitive challenges.

Pharmacological Intervention: Consider medication for mood stabilization or to manage

aggressive outbursts, if necessary.

Follow-up: Regular follow-up to monitor progress, adjust treatment, and provide ongoing
support

Assessment Done by: Supervised By:

 Aashi Jhawar Dr. Ajay Sharma
M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288

Sri Aurobindo Medical College and University, Indore, M.P.

Department of Clinical Psychology

CASE HISTORY No.: 40

IPD No.: 915802

SOCIO-DEMOGRAPHIC DETAILS:

Name: R P

Age: 19

Gender: Female

Education: Neet Preparation

Occupation: Student

Marital Status: N/A

Socio-economic Status: Lower Middle

Locality: Sub-urban

Referred By: Department of Psychiatry

Informant: Father

Reliability of Information: Satisfactory

Adequacy of Information: Adequate

CHIEF COMPLAINTS:

Patient: “the patient wasn’t speaking anything’

Informant: “sir bhari hots hai”

“hawa mai aa gyi thi”

“dath bandh kar liye the bol nhi pari thi”

“2-3 din khan nhi khaya tha toh chamch se zabardasti pilaya tha”

“jhadfuk krwane leke gye the toh dar gyi thi”

HISTORY OF PRESENT ILLNESS (HOPI):

A one-year-old female was brought to the OPD by her family. She was born full-term
through a normal delivery with a normal birth weight and cry. Her developmental milestones
were achieved on time. The family mentioned that she gets scared easily. After her brother
scolded her for excessive mobile phone use, she became frightened. One day, she clenched
her teeth and was unable to open her mouth, leading her to go without eating for 3-4 days.
The family had to force her to drink using a spoon. Believing that she was under the influence
of some "bad air," they took her to a pandit for a ritual, which only caused her to become
more scared.

Onset: The problem began suddenly after the child was scolded by her brother for excessive
mobile phone use.
Course: The condition has had an acute onset, with specific episodes of intense fear leading
to physical symptoms such as clenching her teeth.

Progress of illness: fluctuating

Precipitating Factors: The immediate trigger for the current problem was being scolded by
her brother for using the mobile phone too much.

Predisposing Factors: The child's predisposition to fearfulness might be influenced by her

age, environmental factors, and possibly her overall health and diet.

Perpetuating Factors: The lack of proper understanding and potentially supportive responses
from the family, such as taking her to a pandit for a ritual, may be worsening or maintaining
her symptoms.

Protective Factors: N/A

Negative History:- no history suggestive of head injury

PAST MEDICAL HISTORY: N/A

PAST PSYCHIATRIC HISTORY: N/A

FAMILY HISTORY:
PERSONAL HISTORY:

Birth and Early Development: She was born full-term through a normal delivery with a
normal birth weight and cry. Her developmental milestones were achieved on time

Childhood History: her childhood was difficult has there was lack of resources

Education and Schooling History: she completed her 12th

Occupation History: house wife

Menstrual History: at the age of 14

Marital History: she got married when she was 19

Sexual History: her sexual life is normal

PRE-MORBID PERSONALITY:

Social Relations: lack of support because of which she didn’t ad positive relation

Intellectual Activities, Hobbies and Use of Leisure time: N/A

Pre-dominant Mood of patient: The child appears to be fearful and anxious, particularly in
response to being reprimanded.

Character:

 Attitude towards Self: low self esteem

 Attitude to work or responsibility: N/A
 Interpersonal relationships: negative
 Moral and religious attitudes and standards: she visits temple daily

Habits:

Normal eating and sleeping habit

 MENTAL STATUS EXAMINATION (MSE):

General Appearance and Behaviour: she came in with general apperiance

Psycho-Motor Activity: heightened during episodes of fear or anxiety.

Speech: developed

Mood and Affect: anxious, with a fearful affect.

Thought:

 Stream: disrupted during episodes of fear.

 Form: N/A
 Possession: N/A
 Content: The content of her thoughts may include fear and anxiety, particularly
related to being scolded and the rituals performed.

Perception: The child may perceive certain situations, such as being scolded or undergoing
rituals, as threatening, leading to her symptoms.

Cognition: Cognitive functions, such as memory and attention, are not specifically
mentioned but may be impacted by her anxiety.

Judgment: impaired during episodes of intense fear.

Insight: Insight into her condition is likely limited, especially given her young age and the
family's beliefs.

IMPRESSION: Dissociative Disorder

PSYCHOLOGICAL ASSESMENT:

Rationale for Psychological Assessment dissociative symptoms

Areas to be Investigated Evaluation for diagnostic clarification

Test Administered
7- Rorschach- ink blot test
 8- Thematic Apperception Test
9- Sentence Completion Test

Clinical Observation and test behaviour:

She presented an overall neat and well-groomed appearance. she demonstrated awareness of
her surroundings and maintained proper eye contact. Her attitude towards the examiner was
reasonably cooperative, and a rapport was successfully established. While initially struggling
in ror, she eventually completed the test. Her speech exhibited audible intensity with a normal
speed.

Rorschach Ink Blot

Structural Summary:

Location Features Determinants Contents Approach

Zf= 12 Single H=0 I = W.W

ZSum=31.5 M= 0 (H) =2 II = D.D
ZEst = 38 FM =4 Hd = 1 III = D

m=1 (Hd)=0 IV = W.D.Dd

W=7 FC = 0 Hx = 0 V = W.W

D = 12 CF = 1 A= 9 VI =D.D
Dd = 3 C=0 Ad =1 VII = Dd
S=0 Cn=0 (Ad)=0 VIII = W.D.D
DQ FC’=0 An=2 IX = D.W
+=5 C’F=0 Art=0 X = D.Dd.D.D
O =13 C’=0 Ay=0
V =3 FT=0 BT=3
V/+ =1 TF=0 Cg=1
T=0 CL=0
FV=0 Ex=0
VF=0 Fd=0
Blends:0 V=0 Fi=0 Special scores
FY=0 Ge=0 LVL1 LVL2
YF=0 Hh=0 DV=1 0
Y=0 Ls=0 INC=1 1
Fr=0 Na=0 DR=0 0
Rf=0 Sc=2 FAB=0 0
FD=0 Sx=0 ALOG=0
F=16 Xy=0 CON=0
Id=1 Raw Sum 6=3
(A)=0 Wgtd=7
 (2)=9
AB=0 PHR=2
AG=1 GHR =1
Form Quality COP=1 MOR = 0
FQx MQual W + D=19 CP=0 PER=0
+=0 +=0 +=0 PSV=4
o=6 o=0 o=6
u=9 u=0 u=7
-=7 -=0 -=6

Ratios, percentages and Derivations

R = 22 L = 2.6
EB = 0:1 EA =1 EBPer = 0 FC: CF + C = 0:1 AG = 1
eb = 5:0 es = 5 D = -4 Pure C = 0 a: p = 4:1
Adj es =3 Adj D =4 SumC’: WsumC =0:1 Human Cont. =3
P=2
FM = 4 SUMC=1 WSUMC=1 Afr = 0.69 Pure H =0
m=1 SUMT=0 SUMC’=0 S=0 2AB+(ART+Ay) =0
SUMY=0 Blends: R =0:22 ISOLATED R=0.22
CP = 0 Zd= -6.5

a: p =4:1 Sum6 = 3 XA% = 0.68 Zf= 12 3r + (2)/R =0:40

Ma: Mp = 0 Lv2 = 1 WDA% = 0.68 W:D: Dd =7:12:3 Fr + rF = 0
Mor = 0 Wsum6 = 7 X-%= 0.31 W:M = 7:0 SumV = 0
M- = 0 X+% = 0.27 DQ+ = 5 MOR = 0
Xu% = 0.40 DQv= 1 H: (H) + Hd + (Hd) =0:3
PTI = 1 DEPI = 3 CDI = 2 S-CON= 4 HVI= no OBS= no

Interpretation

The findings suggest that the patient has more sturdy tolerance for stress than do most.
Scores also suggest that the patient has limited resource.
Findings suggest that patient is experiencing some kind of distress.

The patient is experiencing more internal demands than he or she can respond to easily or
effectively. As a result, the capacity for control is lessened, decision or behaviour may not be
well thought through or implemented, and a proclivity for impulsiveness exists.

Findings suggest that the patient is very attracted by emotional stimulation and apparently
quite interested in emotional exchange. People such as this apparently are more intrigued
with or reinforced by emotional stimuli.

Scores signifies an underincorporative form of scanning activity. In other words, the patient
scans hastily and haphazardly, and often may neglect critical bits or cues that exists in a
stimulus field.

Findings suggest that the patient has difficulty in shifting attention.

Scores also suggest a significant mediational impairment.
Tha patient signals likelihood of a serious mediational impairment.
The scores also suggest that there is reality distortion.

The findings indicates that, at times, there is a serious breakdown in the cognitive operations
related to mediation that is not unlike that found when psychotic-like activities are present.
Findings suggest that there is a substantial likelihood of more atypical or even inappropriate
behaviours than might be expected. The proneness towards unconventional behaviours is
most likely to be induced by forms of mediational dysfunctional and problems in reality
testing.

Scores suggest that the patient is avoidant-introversive. Avoidant introversive are ideationally
oriented, but they differ substantially from the true introversive. Although they are prone to
delay decision while considering various options, the domination of the avoidant style usually
causes the process to be less thorough and their conceptual activities are likely to be marked
by much more simplicity.

Findings suggest that it can be presumed that the ideational sets and values of the individual
are well fixed and relatively inflexible.
Test Impression

The assessment findings indicate a complex interplay of cognitive and emotional factors in
the patient's psychological profile. On one hand, the patient displays a notable resilience to
stress, suggesting a sturdy tolerance compared to the general population. However, this
resilience is counterbalanced by limited internal resources, contributing to a state of distress.

Furthermore, the patient exhibits difficulties in managing internal demands, leading to

diminished control over decision-making and behaviour, along with a propensity for
impulsivity. Emotional stimuli hold a significant allure for the patient, indicating a
heightened interest in emotional exchanges and a preference for such stimulation.

Cognitive functioning appears to be compromised, with evidence of underincorporative

scanning activity, attentional shifting difficulties, and significant mediational impairment.
This impairment extends to reality testing, with indications of reality distortion and a
breakdown in cognitive operations resembling psychotic-like activities.

The patient's avoidant-introversive style further complicates the picture, characterized by

ideational orientation yet marked by avoidance and simplicity in decision-making processes.
This rigidity suggests entrenched ideational sets and values, contributing to inflexible
behaviour patterns.

In summary, the patient's psychological profile reflects a nuanced combination of resilience

and vulnerability, with difficulties in cognitive processing, emotional regulation, and
decision-making. These factors may contribute to atypical or inappropriate behaviours, often
influenced by avoidant-introversive tendencies and impaired reality testing

Sentence Completion Test

According to the patient her father always seems stressed and anxious. Whenever she faces a
problem, she feels like there's no one there to support her. She believes that if she had the
power, she would ensure fairness and justice. She's constantly worried about not doing
anything wrong and fears making mistakes. Despite seeing herself as a good person, she
wonders why people speak ill of her. She holds onto hope for the future, seeing finding a job
as the key to her happiness. She regrets her decision to study in Kota. She feels like her
family treats her as if she were plucked from somewhere else. She's always afraid of doing
something wrong and dislikes women who gossip behind others' backs.

Thematic Apperception Test

Thematic Apperception Test was conducted to gain insights into her internal thoughts,
emotions, and psychological functioning.

Integrated Summary of the test-

  Main Theme: The main theme of the story revolves around low financial condition,

and interpersonal conflict.

 Main Hero: The main hero of the story was a female and can and cannot be identified
with self.

 Intellectual level: The narrative plots lacked structure, authenticity, and completion,

appearing disorganized and insufficient. The stories lacked proper organization and

exhibited a level of imagination that was below satisfactory, indicating a less

advanced intellectual capability in the subject.

 Emotional maturity: The patient’s emotional maturity is not in accordance to her age

and sex.

 Personal adjustment: Her personal adjustment is not satisfactory.

 Social Adjustment: She has inadequate interpersonal relations.

 Needs of the Hero: The dominant needs of the hero are need for succorance,

dejection, acquisition and achievement.

 Feelings And Emotions: sad, pity, jealousy, inferiority and worry.

 Significant conflicts: Conflicts relating to interpersonal conflict, emotionality, and

financial condition.

 Nature of Anxieties: The main nature of anxieties was lack of support, emotional

understanding, financial condition and interpersonal conflict.

 Main Defenses: no significant defence.

3. Ego-structure: super ego.

Basic personality: The dominant traits of the hero are emotionality, distrust, self-doubt,
endurance, and anxiety ridden

Test Impression
The patient's narrative revolves around themes of financial hardship and interpersonal
conflict, featuring a female protagonist who may or may not represent the patient herself.
However, the storytelling lack’s structure, authenticity, and completion, indicating an
intellectual capability below satisfactory level. Emotional maturity seems mismatched with
the patient's age and gender, with personal and social adjustments appearing unsatisfactory.
Interpersonal relations are inadequate, and the dominant needs of the hero include
succorance, dejection, acquisition, and achievement. The story evokes feelings of sadness,
pity, jealousy, inferiority, and worry, while significant conflicts revolve around interpersonal
dynamics, emotionality, and financial struggles. The main anxieties stem from a lack of
support, emotional understanding, financial stability, and interpersonal conflicts

DIAGNOSTIC FORMULATION:

Points in Favour: Sudden onset of symptoms following a scolding.

Increased fearfulness, particularly in response to specific situations.

Cultural practices may be exacerbating her anxiety.

Points in Against: No previous history of psychiatric or medical issues.

Normal development and milestones achieved.

PROGNOSIS: The prognosis may be guarded, depending on the family's understanding and
response to her condition. If supportive measures are taken and the child is given a safe
environment, her condition may improve. However, if the family continues to rely on
spiritual rituals that exacerbate her fear, her symptoms may persist or worsen.

DIFFERENTIAL DIAGNOSIS: Acute stress disorder

Separation anxiety disorder

Somatic symptom disorder

Pediatric anxiety disorder

MANAGEMENT PLAN:

Psychoeducation: Educate the family about the potential psychological causes of her
symptoms and the importance of reducing stressors.
Behavioral Interventions: Introduce techniques to help the child manage fear, such as
relaxation exercises or gradual exposure to feared situations.

Family Counseling: Encourage the family to provide a supportive environment and avoid
punitive or frightening practices.

Monitoring: Regular follow-ups to assess the child’s progress and adjust the management
plan as needed.

Assessment done by: Supervised By:

Aashi Jhawar Dr. Ajay Sharma

M.Phil. Clinical Psychology Associate Professor, HOD and Course Coordinator
Trainee (2023-2025) Dept. of Clinical Psychology
Department of Clinical Psychology Consultant Clinical, Neuro and Child Psychologist
Sri Aurobindo University, Indore Sri Aurobindo University, Indore
RCI-CRR. No. A 25726
IACP NO Fellow F-288