1. Case Discussion
• A 22 year old medical student, single,
comes from a middle socio-economic
background
• Brought by mother to psychiatric OPD
• Incident at referral : She left the Forensic
theory paper half-done and came home

2. Presenting Complaints
According to Student
According to mother
(2 months)
•Increasing difficulty in
concentrating on
studies
•Disturbed for the last 1
year and behaving oddly
•Poor memory
•Aggravated condition for
last two months
•Failing in tests recently

3. Events of the last year…
1 YR
BACK
Didn’t receive title at class
function. Cry easily, drink water
excessively. Attention to physical
appearance
10 MONTHS
AGO
Lost company of friends. Saw
undergarments hanging on streets.
Songs in taxi played for her.
Fearful of boy next door trying to
rape her
Believed family is trying to poison
her/her uncle is trying to rape her.
Uses additional locks on her room
and sleep + appetite has reduced
6 MONTHS
AGO
2 MONTHS
AGO
Says brothers are making her
movie

4. Past History
• No past psychiatric or relevant medical history
• Personal history :
- Born full-term, no complications
- Milestones achieved appropriately
- Easy child, started school at 5
- Attachment to father. Father was a patient
of
brain tumor and died when she was 10
- A high achiever who was ambitious
And chose the medical profession herself

5. Family Psychodynamics
• Family history : 2 nd in sibship of 4
2 brothers and a sister
Mother is bread-earner (gets rent
from a house)
• Living pattern : 3-storey house with 2 rooms on
each floor
Ground and middle floors used
by
grandmother and maternal
uncle’s
family

6. Premorbid Personality
• An ambitious and optimistic individual
• Very sensitive to criticism, short-tempered
• Healthy interpersonal relations with family and
friend circle active
• Mother and friends – trusting relations
• Confident and dominating
• Takes responsibility around the house on will
• Worrier
• Poor control over expressions of anger/hurt
• Likes reading books, listening to music
• Fairly religiously oriented
• Satisfied with self
• Low tolerance to stress

7. On Physical Examination…
• Underweight
• Signs of Anemia
• Rest of the Examination was unremarkable

8. On Mental State
Examination…
•
•
•
•
•
•
•
•
Restless and awkwardly confused
Mood was variable (mostly euthymic; also low)
Times when she grew blank
Thought process :
- Organized delusional system (next slide)
- Suicidal ideation
Perception : no abnormality
Oriented but concentration impaired
Thinking was concrete
Lacked insight into her medical condition

9. Delusional System
Delusion of
reference…
“The taxi songs are
for me”;”Boys of
the class follow me”
AUDITORY
HALLUCINATIONS
Sexual Delusions…
“Brothers make my
video while I sleep”;
“Undergarments
hang by ropes
where I go on
streets”
Delusions of
persecution…
”Family wants to
poison me”;
”Friends misguide
me”; “Uncle
wants to rape me”
SOMATIC
HALLUCINATION
OF LOWER BODY

10. Diagnosis
PROVISIONAL DIAGNOSIS
Acute Psychotic Episode
DIFFERENTIAL DIAGNOSIS
- Affective Disorder
- Schizophrenia
MEDICAL DIAGNOSIS
- Anemia

11. Investigations
• PHYSICAL INVESTIGATIONS
- Blood Complete Picture (Hb level)
- Other baseline investigations (Urine R/E,
ECG, Liver and Renal Functional Tests)
• SOCIAL INVESTIGATIONS
dynamics
- Detailed account of history and family
• PSYCHOLOGICAL INVESTIGATIONS
- House/Tree/Person test (maternal
dependence;
immature; confused thinking; ideas of
paranoia
and sexual pre-occupations; fantasy-seeking;
poor ego)
- Beck’s Depressive Inventory (low score)

12. Management
THREE LEVELS OF
MANAGEMENT
BIOLOGICAL
Iron supplements
Antipsychotics
Anti-depressant
PSYCHOLOGICAL
Supportive Therapy
Daily Activity Chart
Study-plan
Relaxation exercises
SOCIAL
Educating family
Family Therapy