Case Conference

Presenter : Ruchi Trivedi

M.PHIL-II (Clinical Psychology)
Chairperson: Dr. Rejani.T. G

Sociodemographic Details
Name: Mrs. K
Age: 22 years
Education: 8
th
standard
Socio-Economic status: Lower middle class
Profession: employed (beauty parlour)
Marital status: Married
Family type: Joint family
Informant: self, husband and mother
Source of Referral: OPD, HMH, Ahmedabad
Reliability and adequacy: Reliable and Adequate

Chief Complaints:
Loosing consciousness
Gets angry frequently
Preoccupied about thoughts related to marital conflict and
deceased daughter
Feeling sad and cries at times
Feelings of guilt
Attempt to injure self
Decreased sleep, Less interest in self care and Loss of
interest in sexual activities


Total duration: since 1 year 4 months
Contd
Onset- Abrupt
Course- continuous
Progress- improving

Precipitating factor: restrictions at in-laws place,
stress during pregnancy
HISTORY OF PRESENT ILLNESS
Index patient was apparently alright till January 2013 (1year
and 4 months back). She was in her first trimester during
this time. She had gone to a temple with her husband to
spend their monthly anniversary. While coming back she
complained that someone was trying to choke her. They
stopped by another temple to take rest which is when she felt
heaviness in head followed by loss of consciousness. She
stayed unconscious for few minutes, unaware about
surroundings, with no injuries. Once she regained
consciousness, she behaved aggressively and talked as if
she was possessed by a spirit that said - anu jiv lavanu
che. This continued for hours. She was then taken to a faith-
healer who suggested that she should be confined to a room
with her husband for 15 days at her parents place.

HOPI ...........................contd
During these 15 days, she had several episodes of loss of
consciousness, throwing things, trying to choke herself,
getting angry frequently. As there was no improvement in
her condition, she was shown to various faith-healers for
the next 15 days. There were continuous conflicts between
the maternal and in-laws about the choice of faith-healers
and rituals to be followed. Mrs. K started staying at her
maternal home. The symptoms of losing consciousness
followed by aggressiveness stopped. But she continued to
get angry frequently.
HOPI ...........................contd
The next 2 months, Constant disputes with the family kept
her preoccupied with thoughts related to the argument,
which made her feel that she was less understood by
others. She felt as if all her family members were being
authoritative and controlling She felt/feels angry because
she didnt know whom to talk to or whom to confide in. She
ends up abusing, blaming and insulting others. She reports
that she regrets doing that once she calms down.
HOPI ...........................contd
In March 2013, on her request for an evening outing, her
husband took her out for a drive. While coming back they
had an argument. She was requesting him to come and stay
with her at her maternal place. She continued arguing with
him, sat on the road, and refused to go home till the husband
wasnt convinced. People gathered around them and
suggested the husband to take her home. Her husband
dragged her home. They continued to argue at her maternal
home, which is when the husband slapped her. She went
unconscious. Woke up after 2 hours. After few minutes she
fell unconscious with rigidity of hands and legs, unaware
about the surroundings, face turned to one side for
approximately 2 mins. She was then taken to civil hospital.

HOPI ...........................contd
Later she was brought back to in-laws place. Her husband
fulfilled all her demands. There were frequent
hospitalization for pregnancy (second trimester) related
complaints, such as recurrent vomiting, weakness,
fatigability and breathlessness.
After the birth of her daughter in June 2013, she continued
to get angry frequently, have frequent arguments with in
laws and husband about the usage of mobile, going out and
meeting friends. She reports that she feels angry, irritated
and unhappy because nobody understands her.


HOPI ...........................contd
In December 2013, her daughter had a fit ( rigidity, mouth
froathing) after Mrs. K fed her. The infant died on the spot in
her hands. Mrs. K was alone at home that time and she
believes that she killed her daughter.
She reports that she feels very sad when she thinks of her
daughter or looks at other babies. She has flashbacks of her
baby dying in her hand. She has disturbed sleep due to these
thoughts. She has dreams of her child. She doesnt feel
interested in maintaining sexual relationships with her husband
like before. She started falling unconscious 2-3 times a day for
few minutes, often getting hurt. As per the informants this
happened only when she is at in-laws place.
HOPI ...........................contd
She started to harm herself when things were not done her
way. She would blackmail the family that if they didnt do
according to her she would harm herself. For example, if she
was not allowed to go for an evening outing, she would use the
blade to cut herself. Till now she has injured herself couple of
times with a blade, causing slits on her hand.
On having an argument with her husband one day, she went
outside the house, and attempted to commit suicide by slitting
the wrist by a blade. She was then rushed to the hospital.


HOPI ...........................contd
After this incidence, she was sent back to her maternal
home. She was given an ultimatum that she will be brought
back to her husbands place if she recovers in 9 months. If
she doesnt recover then steps to divorce will be taken.
Since then she has fewer episodes of falling unconscious
with rigidity of hands and legs, but no injury. She reports
feeling sad most of the times in a day. She came along with
her mother and husband to HMH, OPD in the last week of
March.
PAST PSYCHIATRIC/MEDICAL
HISTORY
At the age of 14- On diwali, her childhood friend (Ms.X) convinced her to
accompany her in running away from home to get married. She was
forced by Ms. Xs in-laws to get married to the elder brother. She denied
complying and so they didnt let her leave the house. She was kept
confined for a week. She tried using the phone to call her family, but was
caught and tied up for 3 days with no food; she managed to escape and
witnessed a road accident, killing a mother and child on the way; She
was caught and brought back. Was rescued by police after a day or two.
this incident had huge impact on her for months. She had flashbacks, 4-5
times loss of consciousness, fear of being held hostage and loss of
interest. She reported that she could come out of it within 6 months due
to family support.
Got operated for appendix when she was 13 years old


TREATMENT HISTORY
Several gynaecologist visits
October 2013 private psychiatrist- Anxiolytics
and Anti-Depressants
Diagnosis: Conversion
February 2014- civil hospital- Anxiolytics and Anti-
depressants.
Diagnosis: Conversion
March 2014- HMH- Anxiolytics and Anti-
Depressants (SSRI)
(clonazepam, sertraline, diazepam)
Currently well adhering to medical regime .
Referred for psychotherapy.

NEGATIVE HISTORY
No history suggestive of shaking spells, strange sensations,
mouth froathing and tongue-biting.

No history suggestive of mood swings, elevated mood,
overactivity, and tall claims.

No history suggestive of recurrent and irresistible urge to
perform certain behaviours.

No history suggestive of false unshakeable beliefs,
hallucinations and substance use.

FAMILY HISTORY
No history of mental illness in the family








No history suggestive of hypertension, diabetes or any physical ailment
Maternal- joint family
In-laws- nuclear
Frequent arguments with the husband.
Impaired relationship with sister-in-law (critical comments) (maternal)
Emotional over involvement/indulgent.

PERSONAL HISTORY
Birth and early development Full term normal delivery at
the hospital; birth cry present; developmental milestones
were attained at appropriate age.
Childhood and adolescence
No particular childhood problems reported
At the age of 13- got operated for appendix
At the age of 14- On diwali, She experienced a traumatic
event.
PERSONAL HISTORY.contd
Scholastic Started school at 5 yrs of age from Nursery and
completed education till 8
th
standard; enjoyed school; no
disciplinary issues/complaints from school. As per Mrs. K,
she used to get approximately 60% in academics. She left
studies after the appendix operation. Reasons- stay weak
and lost interest in studying.
Occupational - started working at the age of 17 (beauty
parlour). Stopped when she got married. She resumed
working few days back.

PERSONAL HISTORY.contd
Sexual/Marital married at the age of 20 years (Sep 2012).
She met her husband 15 days back and found mutual liking
for each other. As family was against love marriage, they
eloped and got married in a court. After marriage, they stayed
out of station for one week. The lawyer helped them get
approval from both the families. They were accepted and
treated with love and respect.

-There are frequent arguments related to usage of mobile,
friends, going for outings, and family related issues.

- Mrs. K feels loss of interest in sexual activities.

PREMORBID PERSONALITY
Disciplined
Easy going, flexible, well- adjusted
No issues initiating and maintaining friendships
Respect for elders
Confident
Disturbed by negative remarks or criticism

MENTAL STATUS EXAMINATION

Well kempt and well groomed; looked age appropriate;
Co-operative; eye contact maintained
Psychomotor activity within normal limits
Spoke in an audible voice and clearly; speech was
relevant and coherent
Thought stream and form was normal; content
comprised preoccupation of deceased daughter, guilt
and marital conflicts.
No perceptual abnormalities were found
Mood was sad subjectively as she said- mann bilkul
saru nathi....bau udass chu., affect was congruent to
mood and appropriate to context.




MSE................contd
She was well oriented to time, place, person, date, day,
month and year. Attention was easily aroused and
concentration was sustained for a considerable period of
time. In memory, immediate, recent and remote memory was
found to be intact.
On the basis of general information, calculation,
comprehension and vocabulary she has average level of
intellectual functioning.
Her personal and social judgment is impaired and test
judgment was found to be at satisfactory.
Insight was at grade-III, as she says hu gandi nathi, loko
samjhe che ki hu gandi chu, mane dukh che, koi samjhatu
nathi, chokri gayi che mari, thodok samay lagse, su karay, jivu
toh padse ne. (partially present)


Case Summary
Mrs. K, 22 years old, 8
th
standard education, Lower class, employed
(beauty parlour), Married
Presenting with complaints of loss of consciousness, getting angry
frequently, preoccupied about thoughts related to marital conflict and
deceased daughter, feelings of guilt, feeling sad and cries at times, ,
attempting to injure self, decreased sleep, less interest in self care, and
loss of interest in sexual activities since 1 year 4 months, with abrupt
onset, continuous course and improving progress.
Precipitating factors are restrictions at in-laws place and stress during
pregnancy.
Started with heaviness of head followed by loss of consciousness,
possession by a spirit and display of aggressive behaviour. As per
informant they got rid of the spirit, after which frequent anger outbursts
occurred. Constant disputes at home kept her preoccupied with thoughts
related to the disputes. Death of her daughter was again a very stressful
event in her life which led to feeling guilty and sad, resulting in disturbed
sleep and loss of interest in sexual activities.





Case Summary.contd
Various hospitalization due to gynecological condition. 2
visits to different psychiatrist before approaching HMH. She
was diagnosed as suffering from Conversion Disorder. She is
currently taking anxiolytics and anti-depressants.
No family history suggestive of mental or physical ailments.
She had to face couple of traumatic experiences during her
adolescence.
Her premorbid personality, as per informant, she was
disciplined, easy going, flexible, well- adjusted, no issues
initiating and maintaining friendships, respect for elders,
confident and would get disturbed by negative remarks or
criticism.


Case Summary.contd
On MSE, she looks well kempt, age appropriate, cooperative,
maintains eye to eye contact, with normal motor behaviour,
speech, thought stream and form. Thought content comprised
preoccupation with thoughts of deceased daughter, guilt and
marital conflicts. No perceptual abnormalities were found. Mood
was sad subjectively as she says man bilkul saru nathi
lagtu....bau udass chu., affect was congruent to mood and
appropriate to context. She was well oriented to time, place,
person, date, day, month and year. Attention was easily aroused
and concentration was sustained for a considerable period of
time. In memory, immediate, recent and remote memory was
found to be intact. she has average level of intellectual
functioning. Her personal and social are impaired and test
judgment was found to be at satisfactory. Insight was at grade-III,
as she says hu gandi nathi, loko samjhe che ki hu gandi chu,
mane dukh che, koi samjhatu nathi, chokri gayi che mari, thodok
samay lagse, su karay, jivu toh padse ne

Diagnostic Formulation
Mrs.K, 22 yrs old, female, married, belonging to lower middle class,
currently employed, residing in a joint family, consulted HMH with
presenting complaints of loss of consciousness, getting angry frequently,
preoccupied about thoughts related to marital conflict and deceased
daughter, feelings of guilt, feeling sad and cries at times, , attempting to
injure self, decreased sleep, less interest in self care, and loss of interest
in sexual activities since 1 year 4 months, with abrupt onset, continuous
course and improving progress. She showed signs of anxiety and
depression post to the stressful traumatic experience in the past, which
was undiagnosed. Her premorbid personality suggests that she was
disciplined, easy going, flexible, well-adjusted, no issues initiating and
maintaining friendships, respect for elders, confident and would get
disturbed by negative remarks or criticism. On MSE, thought content
comprises of preoccupation with thoughts of deceased daughter, guilt and
marital conflicts; sadness of mood, affect was congruent to mood and
appropriate to context. Her personal and social judgement are found to
be impaired and test judgment was found to be at satisfactory. Partial
insight is present.


Diagnosis
F44.5- Dissociative Convulsions
F32.1- Moderate Depressive episode
Psychological Assesment
Tests administered:
Hamilton Rating Scale for Depression
Millions Clinical Multiaxial Inventory-III (MCMI-III)

To be administered:
Rorschach Ink Blot Test
Thematic Apperception Test
Hamilton Rating Scale for Depression

Total score: 15 indicative of less than major
depression
Depressive mood, feelings of guilt, suicide,
difficulty falling asleep and disturbed sleep,
agitation subjective tension and irritability, being
forced to eat, loss of energy, fatigability, loss of
libido, denies being ill.
Millions Clinical Multiaxial Inventory-
III (MCMI-III)

Clinical Personality Patterns- Depressive, Negativistic (Passive-
Aggressive) and Masochistic (Self-Defeating)

Severe Personality Pathology- Borderline : relatively high but not
very significant.

Clinical Syndromes- Anxiety, Dysthymia and Post-Traumatic
Stress Disorder

Severe Clinical Syndromes- Major Depression

Debasement scores- high
Management
Psychodynamic Therapy :
Supportive Therapy
Insight Oriented Therapy


Marital Therapy
Family Therapy

Thanks for listening patiently
Suggestions/opinions/queries are welcome