SOCIO-DEMOGRAPHIC DETAILS

1. Name : XX

2. Gender : Male

3. Age : 27 years

4. Address : Village Bhadia, P.S Chauhata, P.S Haroa, N 24 P, pin: 743425

5. Marital Status : Unmarried

6. Mother Tongue: Bengali

7. Education : M.A. Bengali

8. Occupation : Computer Trainer

9. Religion : Islam

10. Residence : Rural

11. Family type : Joint

12. Income
a) Family income : Rs 30000/month

b) Patient’s income : Rs. 10,000/ month

c) Number of family members : 5

History of Present Illness: The client had to face many difficulties throughout his childhood, adolescent
and young adulthood due to financial crisis. The poverty faced by the client since very childhood made
him believed that as he is not privileged like others, he cannot do better in life and future. While
studying in Class- X, before the final examination the client has to undergo appendicitis operation, due
to which he could not study. His performance in the examination was found to be unsatisfactory due to
which he could not get Science stream in the higher secondary. Since then it was noticed by the client
that he started suffering from headache whenever he used to sit for the studies or while over thinking
and also he became very apprehensive about his career. He believed he could not do much in his
future as he failed to take up science. Gradually, he passed higher secondary went to college and then
at university where tension and apprehension regarding his performance remained prevalent
throughout. Since last 4 years, the client is involved with a job as a computer trainer in a school, the
job was not permanent initially due to which the client started feeling low and less confident about
himself. He believed he could be able to have a good professional life.
In 2019, the client suffered from a romantic relationship break-up, and the relationship was of 2 years
of age. It made the client feel sad most of the time in the day.
The client started forgetfulness, had difficulty in attention and concentration, suffered from chest
tightness and weakness whenever faced with any kind of trigger (like conflict with father) since last 3
years. In 2019 July, one fine morning the client was feeling feverish and weak suddenly. Gradually,
his limbs became numb and he became unconscious, he gained consciousness after 5-7 minutes in
approx.
Biological Functioning:
Sleep : decreased
Appetite : decreased
Sexual energy and activity : decreased
Energy : unchanged
Negative History:
There was no history suggestive of
o significant head injury,
o features of physical symptoms with organic basis
o first rank symptoms,
o persistent elevated mood,
o persistent irrational fear regarding any stimulus or situation
o features of physical symptoms with no organic basis
TREATMENT HISTORY:
The client had visited R.G Kar Medical College and Hospital for his current problems. There
he was prescribed medications and is under these medications since last 2 years. In the month
of March’ 2021 he was prescribed the following medicines:
Tab SRT 50
Tab Olanz 5
Tab Li 300
Tab AMT 25
PAST ILLNESS
1. Medical: there were no significant past medical illness reported
2. Psychiatric: there was no significant past psychiatric illness reported
Family Interaction Pattern
Communication- indirect
Decision Making- by the father
Role- the client can play his role adequately in the family
Family rituals- no significant
Cohesiveness- lacks cohesiveness among family memebers
Family Burden- Financial
Expressed Emotions- warmth and critical comments. The critical comments were mainly received
from the father.
Family History of Psychiatric Illness/ Retardation/ Suicide/ Substance
Dependence/ Epilepsy: Aggressive nature of father and suspected mental illness in paternal
grandfather.
PERSONAL HISTORY
1. Birth and Developmental history: informant reported no birth complications during delivery.
The client was born of normal delivery with immediate birth cry present, and all the developmental
milestones were attained on time.
2. Childhood Disorders: none reported
3. Parents and Home situation in childhood and adolescence:
From the very childhood the client has faced poverty, he along with his family could used to eat
properly and also the client has faced problems in his college due to poverty. Apart from that, the
client shared a loving relationship with his mother. He reported that his mother is very supportive
towards him. But his relationship with his father is distant and his father is aggressive in nature. He
also shared a congenial relationship with his elder brother.
4. Academic History
Highest grade completed: M.A. in Bengali
Academic performance was average as reported by the client, but he never used to get satisfied with
his performance.
Peer relationship- he reported that he still has contacts with his college friends, and during his college
days he used to share congenial relationship with his friends.
Disciplinary problems- not reported
Hobbies- story book reading
5. Occupational History:
The client started working at the age of 23 years. The duration of the present job is for
4 years. He is a computer trainer is a Government School. His job is permanent, he is regular in his
job and his work records are satisfactory with static work position, as reported by the client. He also
reported that he has a very congenial relationship with his work colleagues and also mentioned that
they are very affectionate and supportive towards him.
6. Sexual History
The client reports to have gained knowledge about sexuality through his friends during adolescence.
Masturbatory activity was reported be absent
Heterosexual experience was reported to be present with his ex- girlfriend.
Homosexual experiences and sexual deviance were reported to be absent.
7. Habits and Addictions: None reported
8. Premorbid personality: Premorbidly, the client had to face many difficulties throughout his
childhood, adolescent and young adulthood due to financial crisis. The poverty faced by the client
since very childhood made him believed that as he is not privileged like others, he cannot do better in
life and future. This made him to have a negative anticipation about himself and his future; he had
many friends in college and was sociable with them and had no difficulties in occupational and social
areas of functioning and according to him.
He could take responsibilities and used to do college project works. He could do adjustment with the
changing environment had adequate moral values. As per the client, his predominant mood was
euthymic but was always anxious, and sensitive to criticism and rejection.
MENTAL STATUS EXAMINATION
1. General Appearance and Behaviour
a. Appearance: Well kempt and tidy
b. Touch with the surroundings: present
c. Eye contact: present and maintained
d. Hair: Well groomed
e. Rapport: easily established
f. Attitude towards the examiner: cooperative
g. Motor Behaviour: No abnormalities were observed
2. Motor Behaviour: within normal limits
3. Speech
a. Intensity/tone: audible
b. Reaction time to stimulus: normal
c. Speed: normal
d. Prosody: Normal Fluctuations
e. Ease of speech: Spontaneous
f. Productivity: normal
g. Relevant
h. Coherent
i. Goal-directed
4. Volition: There were no significant disturbances of volition
5. Cognitive Functions
a. Orientation to time, place, person, date, day, month and year was intact
b. Attention and concentration could easily be aroused but not sustained for an
considerable period of time
c. Memory:
i. Remote Memory-
1. Intact remote impersonal memory(year of independence)
2. Intact remote personal memory (his birth day, places he went
on holidays)
ii. Recent Memory- Intact (how the client came to the department from
his home, what he had for dinner last night, who came to visit his place
yesterday)
iii. Immediate Memory- inadequate (DF-4; DB-3; word recall: 2/5)
d. Abstraction: conceptual abstraction level (mango & banana- both are fruits,
chair & table- both are furniture)
e. General Intelligence: average level of functioning.
Information- inadequate (Republic Day, Names of current P.M and
C.M)
Calculation- inadequate (serial subtractions of 3 from 30, If I give you
18 pens and you buy 11 more, how many do you have in total, how
much is 15 times 3, if you buy 80 apples and divide it among 5 friends
then how many do each of you get)
Comprehension – adequate (why do we bathe regularly, why do we
save money at bank)
Vocabulary – adequate (pen, ship, kindness, clever)
f. Judgement
Social- Poor
Personal- satisfactory
Test- satisfactory
6. Mood/Affect
a. Subjective Mood: depressed “bhalo lage na akdom”
b. Objective Affect: depressed
c. Depth: normal.
d. Range: restricted
e. Stability: stable
f. Congruent to the thought
g. Appropriate to the situation
h. Communicable
i. Reactive to the stimulus
7. Thought
a. Thought stream: normal
b. Thought form: normal
c. Thought possession: normal
d. Thought content revealed ideas of helplessness, hopelessness, worthlessness,
ideas of guilt and death wishes
SAMPLE TALK: “ kichu bhalo lagena, beche thakar kono ichche ba asha paina,
tubuo kaj to korte hoy kori, kintu khub hotash lage, rag hoy majhe majhe nijer
opor, abar khub oshohayeo lage monehoy jano kono kichu bhalo hobe na ar ”
8. Perception: There were no perceptual disturbances present
9. Other psychopathology: not significant
10. Insight: Grade V (Intellectual Insight)
Counselling Plan:
1. ‘Psychoeducation’
The client was made comfortable and was asked how his previous week was. He reported that after
talking to the therapist he had felt lighter but that problems remained as they were.
He was assured that with therapy things would improve.
He was psychoeducated – psychological aspects of depression, importance of medication and
adherence was told to him. He had a few queries regarding prognosis
(will I ever get cured? Is this called being mad? Do I need to take the medicines forever?) These
queries were appropriately answered.
The parents were also psychoeducated about depression and the role that they could play in the well
being of their son by providing adequate support.
The concept of counselling was introduced. He was also explained how the cognitions are related to
emotions, physiology and behaviour and how they influence each other.
Before closing the session, the session was summarized and necessary clarifications were given.

2. Client was provided with a warm environment, therapist qualities that will foster the warm
environment are:
Empathy
Support
Genuineness
Openness

Client was given certain tasks to do, i.e; activity scheduling. The rational and concept of daily routine
life was clarified to the client.
3. Reflections from the activity were noted in the counselling session.
Journaling was introduced. Thought Record Form was clarified.
4. Introduction of deep breathing.
Deep breathing was introduced to the client. The rational for deep breathing was explained
that how deep breathing helps in the passage of excessive carbon dioxide from the lungs
which has been the result from muscle tension and stress. Deep breathing helps in relaxation.
The deep breathing exercise was demonstrated to the client.
Step 1: Sit or lie down in a comfortable position.
Step 2: Take a deep breath from your nose
Step 3: Exhale the breath though your mouth
The client was advised to practice the deep breathing twice daily for 7 days, initially.
5. Sleep Hygiene: Discussion about sleep hygiene was done. The client was advised to not to use
mobile phone in the sleeping hours or do any activities which is brain draining. Furthermore,
the client was advised to have a light dinner, take a bath with cold water before going to bed.
6. For Anger Management, he was introduced to an anger diary which looked like the following:
Date Trigger Emotion Body Thought Behaviour Consequences
Sensations

He was explained about the concept of triggers, how to differentiate emotions and thoughts along
with body sensations and behaviour.
Homework was given to fill the anger diary
Before closing the session, the session was summarized and necessary clarifications were given.