PSYCHODIAGNOSTIC REPORT

Socio-demographical detail:

Nam: A.Y Age: 18 years Gender: Male

Religion: Hindu Domicile: Urban Education: 11th
Occupation: NA SES: Middle Class Family Type: Nuclear
Marital Status: Unmarried Mother Tongue: Hindi
Informants: Self and Parents
Information: Reliable and adequate.

CHIEF COMPLAINTS

• Increased aggression
• Verbal abusive behaviour
• Violent behaviour
• Checking behaviour 8 Months
• Decreased sleep
• Increased appetite
Worsen for 5 months
Total Duration:
Predisposing Factor: Overprotection and overcare of grandparents.
Perpetuating Factor: Social Isolation

ONSET: Insidious
COURSE: Episodic
PROGRESS: Deteriorating

HISTORY OF PRESENT ILLNESS:

The patient was asymptomatic till July 2018. His entire problem gradually started after his
sister’s wedding. During the ceremony, his father instructed him to do some work. He
immediately became so angry towards his father and threw his mobile phone at him. After this
incident, his father sent him to Patna with his maternal uncle. The patient was with his maternal
uncle for a week. He sought a job there. But he was fired due to his misbehaviour towards his
colleague. After this incident, he was sent to his paternal grandmother’s place. He was severely
distressed about that. As soon as he entered the grandmother’s house, out of aggression, he
threw a small child who was taking a bath in the washroom. The next day he knocked on the
washroom door frequently when his uncle was taking a bath. When his uncle opened the door,
he hit him with a bucket, and his uncle started bleeding and was hospitalized. He used to
become violent when anyone asked him to study. His sleep decreased significantly, and he used
to be irritable always.

Due to all these incidents, he was sent back to his home. His aggression used to increase
significantly. He asked for a mobile phone from his uncle. When he refused, he hit him with a
chair. He had once broken their electric board and used to be violent most of the time. He found
himself unable to work. He would get angry at very small issues. He would also abuse
language. He frequently used to check the door lock and switchboard. He had difficulty falling
asleep. He would try to sleep at around 11, but would not fall asleep before 2-3 AM. When he
would fail to fall asleep, he used to arrange his clothes, arrange the utensils in the kitchen, etc.
During this period, his appetite also increased. He started feeling hungry and asking for food
every hour. Eventually, they consulted a faith healer, after which the symptoms subsided for
5–6 days. However, the aggression returned eventually. In one of his bouts of aggression, he
attacked his mother lethally to the extent that she started bleeding. It made his father file a
formal complaint against him. The police referred him to the hospital for mental health, and he
is currently under treatment.

The patient was able to maintain self-hygiene. His sleep had decreased since 10 months. He
had difficulties falling asleep. He used to arrange clothes in his cupboard repetitively till late
since he was unable to sleep. He also reported that his appetite had increased since 8 months.
He also reported his social interaction had reduced to a great extent since one year. He reported
that he prefers to be by himself all the time. He reported that his activities of daily living were
intact.

Negative History:

No history of

• Sadness of mood, increased fatigability and loss of interest in pleasurable activities.

• Headaches, trembling, sweating, palpitation and dizziness.
• Excessive fear about specific places, objects or people.
 • False belief that others talking about me or trying to harm me or thoughts being taken
away, inserted controlled or known to anyone.
• Hearing voices or seeing things without any external stimulus.
• Use of substances like alcohol and tobacco.
• Head injury and seizures.
• Intelligence deficiency.

History of Past Illness:

In the year 2014, the patient underwent a medical surgery for tonsils. The informants reported
that the client started stuttering after the surgery. In addition to this, they also reported that he
had started drooling at night while sleeping. His classmates used to make fun of his stuttering,
which made him severely distressed. Eventually, he stopped leaving his house due to his lack
of confidence to face people.

The informant reported that the client gradually started getting irritable at home. Whenever he
was asked to go out or to buy things, he would get angry. He would refuse to do the household
work and preferred to watch television the entire day. When his parents used to scold him, he
would laugh at them. He also started watching movies and songs with sexual content on his
personal devices. The informants also reported that meanwhile the patient started repeatedly
checking the washroom door. He would complain that his room was stinking and would check
the bathroom door frequently. This behavior persisted for around two years. When his parents
used to ask about this, he used to break household things out of aggression.

In the year 2016, his aggressive episodes became frequent. Due to this, he was taken for
treatment by a psychiatrist. He was given the diagnosis of schizophrenia and was put on
medications. After taking medications, the informants reported that the client’s appetite started
increasing and he started gaining weight. The informants also reported that he started showing
off his body, saying that his muscles had grown. Whenever he was told that he had gained
weight excessively, he used to get angry and get violent. The violence was directed mostly
towards his father.

In 2017, the patient’s family approached another psychiatrist because they believed that the
earlier medications were not working. The medications were changed. The informants reported
that these medicines were effective. Within a period of a few months, they observed the
symptoms decreasing. After they observed the symptoms improving, they stopped the
medications by themselves within 5-6 months of starting the medications. After stopping the
medications also, the symptoms were under control.

Medical history: When the patient was 6 months of age, he had one clinically insignificant
head injury. The patient underwent medical surgery for a tonsil when he was 14. Informants
reported that the symptoms started after the surgery.

Family History:

51 4
3

18 1
5

The patient lives in a nuclear family in Maninagar, Ahmedabad. His father is a government
employee, and his mother is a housewife. The patient maintains a good relationship with his
family. He is more attached to his mother. His sister is 15 years old and studying in 10th grade.
There is no family history of consanguinity, mental retardation, or epileptic seizures.

Personal History:

Birth history: Full-term C-section delivery in hospital; birth cry was present; birth weight was
2.7 kg. Vaccinations were provided as per schedule. The developmental milestone was normal
and attained on time.
Childhood history: No abnormality was reported in the patient's early childhood. He was close
to all family members, especially his mother. He was never got into trouble for his behavior.
There is no history of nail biting, stealing, lying, unusual thumb sucking, bed wetting, attention-
seeking behavior, or unusual habits till 8 years. Than his behavior, there were significant
changes.

Home atmosphere in childhood and adolescence: The home environment was congenial,
and the parents were extremely cooperative and supportive. His grandmother was so
overprotective and overcaring that she did not allow him to mingle with the children of his age.
He used to get irritated when his father used to compare him with his sister, who is good in
academics. He used to get into verbal fights with his younger sister whenever she got gifts from
her parents for her good academic performance. The patient reported that he enjoys watching
Bollywood movies and action movies.

School history: Started going to school when he was 5 years old. He studied at the same school
from STD 1-4. There was a significant change in behavior when he was in 4th grade. He used
to use abusive language to girls, pee in the flower pot, eat food from his classmate’s lunchbox,
etc. He shifted to Ahmadabad in 5th grade and studied there till 9th grade. During that time, his
He had problems with attention and concentration; he didn’t finish his schoolwork on time, and
when he was punished for not completing his work on time, he used to laugh and misbehave
with the faculty members. When he was 9, he got into a fight that was physically abusive with
his classmates, due to which his teacher changed his section. He was given grace marks in
order to get promoted, but his father refused it and got him detained. Henceforth he repeated
9std. He gave his board exam with the help of homeschooling as he refused to attain school.

Presently, the patient is in 11th grade, but he refuses to attain school.

Sexual history: Patient reported that he first watched porn when he was 16 and masturbated,
but he has not been involved in any activity recently. Patient has not been involved in any
sexual activity with any girl.

Pre-morbid personality: Patient had difficulty maintaining proper relationships with family,
friends, and society. He spent his leisure time in his house watching actors’s movies, listening
to songs, and playing games on his mobile and laptop. His mood was changeable. He had poor
self-esteem and judgmental skills. His nature was stubbornness and aggressiveness; sometimes
he was self-critical. He is a firm believer in religion. He was very aware of his health. He never
abused substances.

MENTAL STATUS EXAMINATION

General appearance: The patient's appearance is age-appropriate; average height and weight
are physically age-appropriate. Well dressed and well groomed. The patient maintained poor
eye contact throughout the interview.
Attitude towards the examiner: The patient was cooperative and willing to talk to the
interviewer. Rapport was established.
Psychomotor functioning: Patient’s psychomotor activity was normal.
Speech: The patient’s speech was audible and clear but sometimes stuttering. He used to speak
with slow speed, and the speech was relevant and goal-oriented, and productivity was normal.
Mood:
Subjective: The client reported “thik hi raheta he bas kuchh kaam karane ki ichha nahi hoti”
Objective: The patient’s mood was sad.
Affect: The patient quality of affect was dysphonic, the range of affect was restricted and his
reactivity was average.
Thought:
Stream: The patient’s stream of thought was normal.
Possession:

Verbatim:

“Me jab darwaja ki taraf dekhata hu to mere under se vichar aate he ki wo darwaja sahi se
bandh nahi kiya he, to me usko bar bar sahi karane ki kosish karata hu, muje lagta hai ye vichar
me nahi karna chahta fir bhi wo aa jate hai.”

The client reported having intrusive thoughts that he was unable to stop. He would have to
indulge in certain behaviors as a result of those thoughts. He was aware that the thoughts were
of his own but found him unable to control them.

Content:
“Me bimar hu pata nahi muje kya karana chahiae. Muje papa jyadatar bolate rahete he ki kucch
padhai kar le. But muje samaj hi nahi aa raha ki kya karu. Mere friend bhi nahi ban rahe. Aur
banana jata hu to wo kabhi kabhi meri nakkal karate he. To muje achha nahi lagata.”
-Preoccupation with Stuttering
Form: No formal thought disorder was found.
Perception: No perceptual disturbances were reported.

Cognitive functioning:
Attention and concentration: On the digits forward and backward, his attention was aroused
and sustained. He repeated up to 5 digits on the digits forward test and 3 digits on the digits
backward. He was able to perform well on the digit subtraction task (50–3).
The patient’s attention and concentration were aroused and sustained.
Orientation: The patient was well-oriented with time, place, person, month, and year.
Immediate memory: He was able to repeat the three words, like hours, trees, and cars.
The patient’s immediate memory was intact.
Recent memory: He was not able to tell the breakfast and dinner he had the previous day. The
patient’s recent memory was impaired.
Remote memory: He was able to tell me his birth date, primary school name, and other
questions related to past events.
The patient’s remote memory was intact.

General Intelligence:
Abstraction: The patient was not able to tell the meaning of proverbs. The patient’s abstraction
was found to be impaired.

Information: The patient was able to answer the general knowledge questions like the prime
minister of India, the chief minister of Gujarat, and the capital of Gujarat.

Comprehension: The patient was able to understand the given answer related to how to make
curd and why you are celebrating 15 August.

Vocabulary: The patient was able to tell the meaning of pity, jealousy, and charity.

Calculation: The patient was not able to add, substitute, multiply, or divide two-digit numbers.

General Intelligence- the patient’s intelligence appeared to be below average.

Judgment:
Personal:

Q: Yan se thik hokar ghar ja ke kya karo ge?

A: Ghar jake padhai karani hai.

Social:

Q: Ghar mein koi guest ata hai toh kya karte ho?

A: Pahle paani denge fir chai nasta karvaenge.

Test:

Q: Ghar me aag lag jaye toh aap kya karoge?

A: Aag chhoti hai to pani se buja denge nahi to fire brigade ko bulaunga.

The patient’s personal, social and test judgment were found to be intact.

Insight:
‘muje mansik bimari hai mein janta hun par muje pata nahi he kya hai aur kyu hai’
Grade 5: Intellectual insight

DIAGNOSTIC FORMULATION:

The index patient, an 18-year-old, Hindu male, studied up to 11th standard, belonging to
middle-class socio-economic status, residing in urban Ahmadabad was brought to the hospital
by his family members, with chief complaints of increased aggression, verbal abusive
behaviour, violent behaviour, checking behaviour, decreased sleep, increased appetite since 4
years, worsen since 5 months, his mood was sad, affect was congruent to mood, congruent to
thought, in thought content anticipation towards anxiety evoking futures, abnormality detected
in recent memory, abstraction, comprehension and calculation was not satisfactory, insight was
found to be at grade IV.

Provisional Diagnosis:
F31.2 Bipolar affective disorder, current episode of mania without psychotic symptoms

PSYCHOLOGICAL ASSESSMENTS
TEST RATIONAL

Wechsler Adult Performance Intelligence Test – PR (WAPIS-PR): The WAPIS-PR is an

IQ test designed to measure intelligence and cognitive ability in adults and older adolescents.

Bender – Gestalt test (BGT) –II: The Bender-Gestalt test was originally developed by
Lauretta Bender and measures visual-motor integration skills, developmental disorders, and
neurological impairments in children and adults. It was considered important to administer it
to this patient to rule out any organic brain dysfunction.

Beck Depression Inventory (BDI) –II: The Beck depression inventory, created by Aron T.
Beck, is a multiple-choice self-report inventory that measures characteristic attitudes and
symptoms of depression. In this patient, BDI was administered to assess the severity of
depressive feelings and thoughts.

Yale-Brown Obsessive Compulsive Scale (Y-BOCS): The Yale-Brown Obsessive-

Compulsive Scale was developed by Goodman et al. in 1989. The Y-BOCS is a 10-item scale
designed to measure the severity and types of symptoms in people with obsessive-compulsive
disorder (OCD) over the past seven days. The symptoms assessed are obsessions and
compulsions. This scale is used fully in tracking OCD symptoms at intake and during/after
treatment.

Young Mania Rating Scale (YMRS): The YMRS, developed by Vincent E. Ziegler and
popularized by Robert Young, is an 11-item multiple-choice diagnostic questionnaire that
psychiatrists use to measure the severity of manic episodes in children and adults.

Millon Clinical Multiaxial Inventory (MCMI) – III: Originally developed by Millon in 1977
(presently 3rd revision, 1994), is a standardized, self-reported questionnaire that assesses a wide
range of information related to the client’s personality, emotional adjustment, and attitude
towards taking tests. It focuses on personality disorders as well as other symptoms commonly
associated with these disorders. It consists of 175 items, scored to produce 28 scales divided
into different categories, namely, modifying indices, clinical personality pattern, severe
personality pathology, clinical syndromes, and severe syndromes.
Rorschach inkblot test: developed by Rorschach (1921) is a widely used projective test that
helps in exploring one’s personality and current psychological state of an individual. It consists
of 10 different cards containing bilaterally symmetrical printed inkblots used as a stimulus for
individuals to project their own images onto them of the administered to understand the
presence of psychotic symptoms and his personality.

Test finding:

Wechsler Adult Performance Intelligence Scale – PR (WAPIS-PR):

His test raw score was 116, and his scaled score was 45. His scaled score indicated his IQ was
88.
The result indicates he has below-average intelligence.

Bender – Gestalt test (BGT-II):

On BGT-II patients, the raw score in the copy phase was 28 and the standard score was 88. The
result indicates he has a low average of visual-motor integration skills. In the recall phase, the
patient's raw score was 1 and the standard score was 70.
The result indicates he has a low or borderline delayed level of visual-motor integration skills.

Beck Depression Inventory (BDI):

On BDI his total score was 28 indicating a moderate level of depression.

Yale-Brown Obsessive Compulsive Scale (Y-BOCS):

The client obtained a score of 10 on the obsession subscale and a score of 5 on the compulsion
subscale. The obtained score on the obsession scale indicates the presence of mild levels of
obsessions. Scores on the compulsion scale are suggestive of the subclinical level of
compulsions on the client.
Young Mania Rating Scale (YMRS): The client YMRS obtained a score of 27, which
indicates a moderate level of mania.

Millon Clinical Multiaxial Inventory (MCMI) – III:

MCMI is based on Theodore Million’s evolutionary theory, which is an objective personality
test that also measures clinical features. It was considered important to study the personality
characteristics as well as the presence of any clinical pathology of the patient.
Clinical Syndromes:

The features and dynamics of the following Axis I clinical syndromes indicate several
enduring and pervasive aspects of the subject's personality makeup.

Anxiety (Scale A): (BR score 95) The person is primarily phobic and more specifically in
social situations. He may have experienced a generalized state of tension, manifested by his
inability to relax and his readiness to react and be easily started.

Bipolar: Manic scale (Scale N): (BR score: 85) He may experience periods of superficial
elation, restlessness over activity, distractibility, impulsiveness, and irritability. There could
also be unselective enthusiasm, excessive planning for unrealistic goals, decreased need for
sleep, and rapid and labile shifts of mood.

Dysthymia (Scale D): (BR score-79) The patient with a high score on the D Scale remains
involved in everyday life but has been preoccupied over a period of years with feelings of
discouragement or guilt, lack of initiative, behavioural apathy, low self-esteem, and
frequently expressed futility and self-deprecatory comments. There may be periods of
tearfulness, suicidal ideation, a pessimistic outlook towards the future, social withdrawal,
poor appetite or overeating, chronic fatigue, poor concentration, a marked loss of interest in
pleasurable activities, and decreased effectiveness in performing routine life tasks.

Clinical Personality Patterns:

The following paragraph refers to those enduring and pervasive personality traits that underlie
this patient’s emotional, cognitive and interpersonal difficulties. Rather than the large transitory
symptoms that make up Axis I clinical syndromes, these concentrate on his more habitual and
maladaptive methods of relating, behaving, thinking and feeling.
He has obtained the highest score on the scale 2A (Avoidant). (BR score-87) The MCMI-
III profile of this patient suggest that they are vigilant and always on guard, ready to distance
themselves from anxious anticipation of life’s painful or negatively reinforcing experiences.
Their adaptive strategies reflect fear and mistrust of others. Despite their desires to relate to
others, they have learned that it is best to deny these feelings and to keep a good measure of
interpersonal distance. He also obtained significant scores on scale 2B (Depression) (BR
score-81). There has been a significant loss, a sense of giving up and a loss of hope that joy
can be retrieved. Similarly, experience can condition a hopeless orientation to a significant loss.
He also obtained significant scores on scale 8A (Negativistic) (BR score-83). Their struggle
represents an inability to resolve conflicts similar to those of the obsessive-compulsive;
however the conflicts of the negativistic individuals experience endless wrangles and
disappointments as they vacillate between deference and defiance, between obedience and
aggressive opposition. Their behaviour is characterized by an erratic pattern of explosive anger
or stubbornness intermingled with periods of guilt and shame. He also obtained significant
scores on scale 3 (Dependent) (BR score-82). There individuals have learned not only to turn
to others for nurturance and security but to wait passively for their leadership in providing
them. They are characterized by a search for relationships in which they can learn on others for
affection, security and guidance. Their lack of initiative and autonomy is often a consequence
of parental overprotection. As a function of these experiences, they have simply learned the
comforts of assuming a passive role in interpersonal relations, accepting what kindness and
support they may find and willingly submitting to the wishes of others in order to maintain
their affection.
He also obtained significant scores on scale 6B (Sadistic) (BR score-80). They are generally
hostile and pervasively combative and they appear to be indifferent to or pleased by the
destructive consequences of their contentions, abusive and brutal behaviour. Although many
cloak their more malicious and power-oriented tendencies in publicity-approved roles and
vocations, they give themselves away by their dominating, antagonistic and frequently
persecutory actions. He also obtained significant scores on scale 1 (Schizoid) (BR score-79).
There individuals are noted for their lack of desire and their incapacity to experience deep
pleasure and pain. They tend to be apathetic, listless, distant and social, their emotions and
affectionate needs are minimal and they function as passive observers detached from the
rewards and affections – as well as from the demands of human relationships.

Severe Personality Pattern:

He also obtained significant scores on scale S (Schizotypal) (BR score-82). Their personality
reflects deeply etched and pervasive characteristics of functioning that perpetuate and
aggravate everyday difficulties. They are so embedded and automatic that the individual is
often unaware of their nature and self-destructive consequences. Especially a deficit in social
competence and frequent psychotic episodes. Less integrated in terms of personality
organization and less affective in coping than their milder counterparts, they are especially
vulnerable to the every day, trains of life.
RORSCHACH INKBLOT TEST:
The following interpretation is done using Exner’s Comprehensive System of Rorschach
Inkblot Method.

He appears at present to be experiencing a fair amount of stress that is giving rise to unpleasant
affect and may make him susceptible to feeling depressed. This person appears to be in a state
of mild but chronic stimulus overload resulting from persistent difficulty in mustering adequate
psychological resources to cope with the demands being imposed on him by internal and
external events in his life. Consequently, he is at risk for recurrent episodes of overt anxiety,
tension, nervousness, and irritability. People with this pattern of stimulus overload tend to have
limited tolerance for frustration and a less-than-average ability to persevere in the face of
obstacles. This person appears capable of attending to his experience in a reasonably open and
flexible manner that constitutes a personality asset. He shows an adaptive balance between
being able to deal with situations in a detached and uninvolved manner sometimes and, at other
times, in a concerned and engaged manner.

He demonstrates an impairment of his reality testing capacity, whereby he tends to misperceive

events and to form mistaken impressions of people and the significance of their actions. This
person is inclined to examine his experience in a cursory manner and to take inadequate account
of information he should consider. He is consequently at risk for being hasty and careless in
the way he makes decisions and works on tasks. He displays adaptive capacity to think logically
and coherently, and is, for the most part, as capable as most people of coming to reasonable
conclusions about relationships between events and of maintaining a connected flow of
associations in which ideas follow each other in a comprehensible manner.

This person is an expressive type of individual who typically lets his actions be guided more
by how he feels than by what he thinks. In making decisions and solving problems, he tends to
favour a trial-and-error approach over thinking about alternative possibilities. He shows a
potentially adaptive repertoire of styles for experiencing and expressing affect in which he
modulates emotions in much the same way as most people. This person appears to compare
himself unfavourably to other people and consequently to suffer from low self-esteem and
limited self-confidence. This person appears to be less capable than most people of dealing
effectively with everyday experience, especially with respect to social situations. This person
gives evidence of limited capacity to form close attachments to other people. Although he may
not necessarily avoid interpersonal relationships, these relationships tend to be psychologically
at arm’s length rather than close and intimate. He shows less interest in other people than
ordinarily would be expected. Such limited interpersonal interest constitutes a personality
liability and is likely to be associated with his having infrequent or mostly superficial
relationships with other people. This person is more likely than most people to demonstrate
ineffective or maladaptive interpersonal behaviour.

SUMMARY OF TEST FINDING:

The patient’s intelligence was below average on WAPIS-PR. His IQ was found to be 88.

BGT-II was a borderline level of impairment in visual motor integration skills.

BDI indicated a moderate level of depression.

YBCOS indicated obsession on mild and compulsion on subclinical.

YMRS indicated a moderate level of manic symptoms.

On MCMI it was found that on the clinical syndrome scale the client scored highest on anxiety,
bipolar and diathermia, on clinical personality pattern avoidant, depression, negativistic,
dependent, sadistic and schizoid, on severe personality pattern schizotypal.

Rorschach all the above findings collectively reveal that the patient is suffering from depression
and underlying anxiety. Though there are underlying isolated features of poor reality testing
capacity and impaired ability to evaluate environmental stimuli in a normal manner those
findings are not sufficient to provide the diagnosis of psychosis or schizophrenia for the patient
at present.

Impression:
Based on test findings the patient has Bipolar Affective Disorder

Suggestions:

➢ Psychoeducation
➢ Counselling to the patients and parents
➢ Cognitive behaviour therapy
➢ Regular follow up