I.

SOCIO-DEMOGRAPHIC DETAILS:

Name : Kumam Achoubi

Age : 33 years old
Sex : Female
Marital status : Married
Education : 10th Standard
Occupation : NA
Religion : Hindu
Address : Sagolband Tera, Imphal West
Referral : Psychiatry Unit
Reason for Referral : Psycho-Diagnostic Evaluation
Referred by : Dr. Rk Lenin
No. of sessions :3
Informants : Client and her husband
Information : Adequate and reliable

II. COMPLAINTS AND DURATION:

The client was presented with complaints of:

• Overthinking
• Social Withdrawal
• Low mood
• Low energy and fatigability
• Suspiciousness
• Reduced Sleep

III. HISTORY OF PRESENT ILLNESS:

The onset of the presenting complaints was gradual. The client was apparently alright until 1
years back. The presenting complaints of the client started appearing when she stopped her
medication for 5 months i.e., since August 2022. Since then, the client has been having
complaints of overthinking, social withdrawal, low mood, low energy and fatigability,
suspiciousness and paranoia, and reduced sleep.
The precipitating factor were family discord where the client feels that mother-in-law and
father-in-law un reasonably criticizes her a lot and verbally abuses her since their marriage.
Due to such discord, her responsibility of taking care of her family has been affected. This
has in turn affected her social interactions with others as well.

The course of the presenting illness is fluctuating (periodic exacerbations of a continuous

illness). The associated disturbances experienced by the client due to the presenting illness
were decreased in sleep, social withdrawal, decline in performance of family duties.

IV. PAST HISTORY:

The client reported he had no significant medical complications before the development of
his symptoms.

V. FAMILY HISTORY:

40 Years 33 Years

9 Years 7 Years

The client hails from a low socioeconomic family. Her husband is 40 years old and is a
school van driver. He is the sole breadwinner of the family. She has a 9-year-old daughter
who is currently in the 3rd standard and a 7-year-old son who is currently in the 1st Standard.
The client shows despise towards her father-in-law and mother-in-law due to the excessive
criticisms and verbal abuse. She thinks that she is looked down upon and treated lesser than a
human.

Medical History of the family:

 Client’s father origin of family: NA

 Client’s mother’s origin of family: NA

VI. PERSONAL HISTORY:

a) Birth and Early Development: The client was born on April 1990. There was no history
of complication during prenatal, perinatal and post-natal period. The client was carried
through full term baby and delivered at hospital by normal delivery with immediate birth cry.
Developmental milestones were achieved.

b) Behaviour during Childhood: The client got along with her peers and family members

c) Physical Illnesses during childhood: No history of major physical illness.

d) School: The client started schooling at age of 5 from nursery till the 10 th standard. The
client’s scholastic performance was average.

e) Occupation: N.A.

f) Sexual History: Client’s onset of menarche was when she was 13 years old. She obtained
knowledge about sex from her friends and media.

g) Marital History: The client got married in 2013

h) Use and abuse of alcohol, tobacco and drugs: No

VII. PRE-MORBID PERSONALITY

1. Social Relations to Family: Client has close attachment with her husband and
children but had conflictual relationship with father-in-law and mother-in-law.
2. Intellectual activities: The client enjoys listening to music and watching movies.
3. Mood & Affect: Client was cheerful and optimistic in nature before the illness.
However, when she was angry, it was difficult for her to calm down and was quick-
tempered.
4. Character-
a) Attitude: Client was overwhelmed with responsibilities and have difficulty
making decisions. She was easily discouraged.
b) Interpersonal Relationships: Client has shy, timid and sensitive to criticism,
quiet and restrained in speech and gesture. She was tolerant of others and
adaptable.
c) Standards: The client has high religious and social concern with adequate
concern regarding health. She was complacent and self-approving in relation
to her own behaviour and had low level of aspiration. She was intolerant to
frustrations,
d) Energy & Initiative: Client was sluggish but fitful and got easily fatigue. She
has experience irregular energy output.
 5. Fantasy habits: Client Day dreams at times.
6. Habits: Client experienced normal sleep before the illness and now has decreased.

VIII. MENTAL STATUS EXAMINATION:

1. General Behaviour – The client was kempt and groomed. Rapport formation was
adequate. Adequate eye contact was maintained. Attention could be aroused but it was
difficult to sustain. The client could comprehend instructions and was oriented to
time, place and person. The client was not overtly expressive but was fairly co-
operative throughout the session.
2. Psychomotor Activity – Psychomotor activity was observed to be decreased
3. Speech – The client spoke only in response to questions. The amount of speech, tone
of voice and tempo was low. The volume of the speech was low. The reaction time
was adequate. Prosody of speech was maintained.
4. Thought – There was no disturbance in the form and stream of thought. However,
content of thoughts included a fleeting belief of suspicion and paranoia that others
might harm her.
5. Mood- Subjective: Dysthymic Objective: Dysthymic
Affect- Subjective: Dysthymic Objective: Dysthymic
6. Perception – No disturbance in perception.
7. Cognitive Functions –
a. Orientation- The client was oriented to time, place and person. The client was
able to tell the day and date accurately. The client knew that she was in RIMS
hospital. She also identified herself and her husband who accompanied her to
the session.
b. Attention and concentration – In Digit Span Test, the client was able to
produce 5 digits and 4 digits correctly in forward and backward respectively.
Counting months forward could be completed in 20 seconds.
c. Memory – Her immediate, remote and recent memory was intact
d. Intelligence –
i. General Information: The client was able to name the prime minister of
the country, capital of the state and the five states of the country.
ii. Comprehensions: The client could understand and give fairly accurate
answers when asked what she would do when she feels cold.
 iii. Arithmetic: In arithmetic test, the client answered accurately for
questions like “How much is 4 rupees and 5 rupees?”.
iv. Abstraction: In abstraction, the client was asked to tell the differences
and similarities between objects.
v. Proverbs: The client understood the concept of proverbs.
8. Judgement: The client has intact judgement ability in personal, social and test
situations.
9. Insight: Grade-IV (Awareness of being sick due to something unknown in self)

The client was found to have average knowledgeable in areas of general information,
comprehension, arithmetic and abstraction. The client has the ability to comprehend and act
adequately when presented with situations that requires her judgement skills.

IX. SUMMARY:

The client, female, Kumam Achoubi, aged 33 was presented with complaints of overthinking,
social withdrawal, low mood, low energy and fatigability, suspiciousness and paranoia, and
reduced sleep.

The client was kempt and groomed. Rapport formation was adequate. Adequate eye contact
was maintained. Attention could be aroused but it was difficult to sustain. The client could
comprehend instructions and was oriented to time, place and person. The client was not
overtly expressive but was fairly co-operative throughout the session.

Psychomotor activity was observed to be decreased. The client spoke only in response to
questions. The amount of speech, tone of voice and tempo was low. The volume of the
speech was low. The reaction time was adequate. Prosody of speech was maintained.

There was no disturbance in the form and stream of thought. However, content of thoughts
included a fleeting belief of suspicion and paranoia that others might harm her.

Her memory was intact. She has Grade-IV (Awareness of being sick due to something
unknown in self) insight.

XI. PROVISIONAL DIAGNOSIS:

F20.0 Paranoid Schizophrenia

XII. DIFFERENTIAL DIAGNOSIS:

 • Major Depressive or bipolar disorder with psychotic features
• Schizoaffective Disorder
• Brief Psychotic Disorder
• Delusional Disorder

PSYCHOLOGICAL TESTS REPORT

Name : Kumam Achoubi
Age : 33 years old
Sex : Female
Marital status : Married
Language Tested In : Manipuri
Education : 10th Standard
Occupation : NA
Date of Administration : 04/01/23; 23/02/23; 27/02/23
No. of sessions :3
Reason for Referral : Psycho-Diagnostic Evaluation

TESTS ADMINISTERED:
1. Brief Psychiatric Rating Scale
2. Positive and Negative Syndrome Scale
3. Hamilton Anxiety Rating Scale
4. Revised Hamilton Rating Scale for Depression
5. NEO FFI-3
6. Rorschach Inkblot Test
TEST FINDINGS:
1. Brief Psychiatric Rating Scale
The Brief Psychiatric Rating Scale was developed by D. Gorham in 1962. It is a 24-item
rating scale that measures psychiatric symptoms such as depression, anxiety, hallucinations
and unusual behaviour. Each item is rated on a likert scale from 1 (not present) - 7 (extremely
severe). The scores are based on clinician's interview with the client and observation of
client's behaviour over 2-3days. The test takes 15-20 minutes. Reliability expressed by intra-
class correlation is 0.78 and validity is 0.66C a.
Conducted by John Andersen, Jens Knud Larsen, Ale Korner, et al. by the name "The Brief
psychiatric Rating Scale; Schizophrenia, Reliabilty and Validity studies." published in July
2009.
The brief psychiatric rating scale were administered. The resultant score of 41 indicates that
the patient is moderately ill.
2. PANSS
The PANSS (Kay et al., 1987) is a rating system that includes a structured interview, which
can be administered in approximately 30 min to provide data alongside clinical observation
and collateral information (e.g., from the chart). The accompanying interview is the
Structured Clinical Interview for PANSS (SCI-PANSS: Opler et al., 1992). It contains
inquiries about some (not all) specific PANSS symptoms in a flexible semi-structured format.
It is not a diagnostic tool, but a severity rating tool that rates 30 symptoms of schizophrenia,
divided into positive, negative and general psychiatric symptoms, over the most recent
week. Lindstrom et al. (1994) showed that high reliability is achieved in rating the PANSS
scales when the SCI-PANSS is employed, rising to intraclass correlation coefficients between
0.83 and 0.99; however, its use is not mandatory for the rating of the PANSS.
The positive and negative syndrome scale has been administered. Resultant score indicates
minimal positive and mild negative symptoms.

3. Hamilton Anxiety Rating Scale:

The HAM-A (Hamilton, 1959) is a clinician administered rating scale designed to assess
anxiety symptom severity. Somatic, cognitive, and affective symptoms are included. The
Hamilton Anxiety Rating Scale (HAM-A) is a widely used and well-validated tool for
measuring the severity of a patient's anxiety. It should be administered by an experienced
clinician. The HAM-À probes 14 parameters and takes 15-20 minutes to complete the
interview and score the results. Each item is scored on a 5-point scale, ranging from 0=not
present to 4=severe. The major value of HAM-A is to assess the patient's response to a course
of treatment, rather than as a diagnostic or screening tool. By administering the scale serially,
a clinician can document the results of drug treatment or psychotherapy. Developed in 1959
by Dr. M. Hamilton, the scale has proven useful not only in following individual patients but
also in research involving many patients.

The Hamilton Anxiety Rating Scale (HAM –A) was administered. The resultant scored 20
indicating features of moderate levels of Anxiety.
 4. Hamilton Rating Scale for Depression:

The Hamilton Rating Scale for Depression (HRSD), also called the Hamilton Depression
Rating Scale (HDRS), abbreviated HAM-D, is a multiple item questionnaire used to provide
an indication of depression, and as a guide to evaluate recovery. Max Hamilton originally
published the scale in 1960 and revised it in 1966, 1967, 1969, and 1980. The questionnaire is
designed for adults and is used to rate the severity of their depression by probing mood,
feelings of guilt, suicide ideation, insomnia, agitation or retardation, anxiety, weight loss, and
somatic symptoms. Assessment lime is estimated to take 20 minutes. A number of studies
have shown the internal consistency of different versions of HAM-D to range widely from
0.48 to 0.92. A recent study reported internal consistency coefficients of 0.83 for HAM-D-17
and 0.88 for HAM-D-24. Inter-rater reliability has been reported to be very high for HAM-D
total scores (0.80-0.98). A sufficiently high inter-rater reliability (>0.60) was reported for
most of the HAM-D items and the total score (0.57-0.73) in a study on inter-rater reliability.
Test-Retest Reliability has been reported to be high as 0.81. Validity of the HAM-D has been
reported to range from 0.65 to 0.90.

The Hamilton Rating Scale for Depression (HDRS also known as HAM-D) was
administered. The resultant score indicates Moderate Major Depressive Episode with
features of Major Depression.

5. NEO FII- 3
NEO Personality Inventory (NEO PI), Revised NEO Personality Inventory (NEO PI-R), and
NEO Five-Factor Inventory (NEO FFI) were developed with the aim of assessing the five
domains of the FFM: (a) neuroticism (N), the tendency to experience negative emotions and
psychological distress in response to stressors; (b) extraversion (E), the degree of sociability,
positive emotionality, and general activity; (c) openness to experience (O), levels of curiosity,
independent judgment, and conservativeness; (d) agreeableness (A), altruistic, sympathetic,
and cooperative tendencies; and (e) conscientiousness (C), one’s level of self-control in
planning and organization. The five domains are hypothesized to be relatively orthogonal to
one another. The NEO inventories are composed of descriptive statements (e.g., “I am not a
worrier,” “I really enjoy talking to people”) rated on a 5-point Likert-type scale (1 = strongly
disagree to 5 = strongly agree). The NEO FFI contains 60 items and may be used to derive
only the five domain scores (12 items per domain). NEO FFI items were selected from the
NEO PI items that demonstrated the strongest correlations with their respective domain factor
score, regardless of the item’s intended facet (i.e., the 30 NEO PI facets are not equally
represented by NEO FFI items). Each of the five domains of the NEO FFI has been found to
possess adequate internal consistency and temporal stability (α = .68 to .86, Costa & McCrae,
1992; r = .86 to .90, Robins, Fraley, Roberts, & Trzesniewski, 2001).

NEO Five Factor Inventory- 3 was administered and the resultant score and interpretation are
given below:

Scale Raw Score T- Score Score level and

interpretation
Neuroticism 37 69 Very High
Expressiveness 29 5 Average
0
Openness to 30 51 Average
Experience
Agreeableness 32 47 Average

Conscientiousness 19 29 Very Low

6. Rorschach Inkblot Test

Rorschach's Inkblot Test is a projective test developed by Hermann Rorschach, a Swiss

Psychiatrist in 1921 with ambiguous inkblot. This test consists of ten cards - five chromatic
and five achromatic, out of which three of them are multi-coloured. The cards have different
names, 1-general, 2-female sex plate, 3-reality orientation plate, 4-male authority plate, 5-
reality orientation plate, 6-male sex plate, 7-female authority plate, 8-reality orientation plate,
9-emotional tolerance plate and 10- organisation capacity and emotional tolerance plate. It
has been employed to detect underlying thought disorder especially in cases where patients
are reluctant to describe their thinking processes openly.

The Rorschach Inkblot test was administered, and the protocol suggests that the client has a
good practical approach and emphasizes on the minute details but has a constricted
intellectual functioning, and a low organising and synthesizing capacity. She has better group
conformity in thinking but a poor ego strength and low reality orientation, and a restricted
awareness of her environment, is suspicious and has paranoid tendencies. Furthermore, she
has an inadequate control over emotion, and has an unsatisfactory interpersonal relationship,
is defensive, in repression and denial, and is afraid of losing control. She is extratensive i.e.,
she can easily release her feelings and emotions outside, with excessive somatic concern.

Low total number of responses, low shape appropriate responses (F+%), Variable Response
Time, Card rejection are indicative of psychosis

SUMMARY

A full-length psycho-diagnostic evaluation was done. A full-length psycho-diagnostic

evaluation was done. The tests administered were Brief Psychiatric Rating Scale, Positive and
Negative Syndrome Scale, Hamilton Anxiety Rating Scale, Revised Hamilton Rating Scale
for Depression, NEO FFI-3 and Rorschach Inkblot Test.
From the case history, clinical observations and psychological tests, it can be suggested that
the client has minimal positive syndrome and mild negative syndrome. In addition, she may
have features of moderate Anxiety, Moderate major depressive episode with Major
depression indicating that the client is moderately ill.

Further, it also reveals that the client has a good practical approach and emphasizes on the
minute details but has a constricted intellectual functioning, and a low organising and
synthesizing capacity. She has better group conformity in thinking but a poor ego strength
and low reality orientation, and a restricted awareness of her environment, is suspicious and
has paranoid tendencies. Furthermore, she has an inadequate control over emotion, and has an
unsatisfactory interpersonal relationship, is defensive, in repression and denial, and is afraid
of losing control.

X. DIAGNOSTIC FORMULATION:

The client, female, Kumam Achoubi, aged 33 was presented with complaints of overthinking,
social withdrawal, low mood, low energy and fatigability, suspiciousness and paranoia, and
reduced sleep.

The onset of the presenting complaints was gradual. The client was apparently alright until 1
years back. The presenting complaints of the client started appearing when she stopped her
medication for 5 months i.e., since August 2022.
A full-length psycho-diagnostic evaluation was done. The tests administered were Brief
Psychiatric Rating Scale, Positive and Negative Syndrome Scale, Hamilton Anxiety Rating
Scale, Revised Hamilton Rating Scale for Depression, NEO FFI-3 and Rorschach Inkblot
Test
The psychological tests conducted suggested that the client has minimal positive syndrome
and mild negative syndrome. In addition, she may have features of moderate Anxiety,
Moderate major depressive episode with Major depression indicating that the client is
moderately ill. The Rorschach protocols reveals client has a good practical approach and
emphasizes on the minute details but has a constricted intellectual functioning, and a low
organising and synthesizing capacity. She has better group conformity in thinking but a poor
ego strength and low reality orientation, and a restricted awareness of her environment, is
suspicious and has paranoid tendencies. Furthermore, she has an inadequate control over
emotion, and has an unsatisfactory interpersonal relationship, is defensive, in repression and
denial, and is afraid of losing control. She is extratensive i.e., she can easily release her
feelings and emotions outside, with excessive somatic concern.

From the clinical interview, behavioural observation and psychological test findings it can be
suggested that the client has features of schizophrenia.

XIII. FINAL DIAGNOSIS

XIV. RECOMMENDATION