A RECORD OF INFORMATION RELATING TO A

PERSON’S PSYCHOLOGICAL OR MEDICAL CONDITION

USED AS AN AID TO DIAGNOSIS AND TREATMENT, A
CASE HISTORY USUALLY CONTAINS TEST RESULTS,
INTERVIEWS, PROFESSIONAL EVALUATIONS, AND
SOCIOLOGICAL, OCCUPATIONAL, AND EDUCATIONAL
DATA ALSO CALLED PATIENT HISTORY
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WHAT IS CLAUSTROPHOBIA?
CASE STUDY- II (Claustrophobia)
• Name - Mr. raman
• Age - 55
• Marital status - Married
• Gender - Male
• Occupation - Businessman
• Education - Graduation/ BA economics
• Religion - Hindu
• Mother tongue - Bengali
• Location of residence - Kolkata, West Bengal
• Socioeconomic status - Middle
• Informant - Brother
• Reliability - Reliable and consistent
 CHIEF COMPLAINTS
According to client
“whenever I am in crowd or I think about being in crowd then I feel uneasy and
get sensation of cold feet and hands.
• I feel like I will die”
• “I have problem to be in closed places like lifts and planes.
• But I also feel anxious when I am alone at home.” Informant states that
• “His condition is causing a lot of distress to his family and they are ready to do
anything to get him treated”
 HISTORY OF PRESENT ILLNESS
Five years ago the client had started showing symptoms of anxiety and panic
attacks. he would have such attacks when he is in closed space or is alone at
home. He would experience racing hearts, cold hands and feet, chest pain,
difficulty breathing and palpitation. He thought he had heart problem. As a
result, he had many physical examinations like ECG etc. But everything came
out normal. He had gone to many doctors for treatment including homeopathy,
naturopathy etc.
 Six months back he was alone at home and fainted in bathroom after panic
attack .as a result general physician advised him to see a psychologist
He has travelled all the way from Kolkata to see a psychiatrist. Since he is afraid of
travelling in plane he came by train whereas his brother came by plane. He feels
that lift will be closed and he will be stuck in lift. He also experiences anxiety
before sleeping and live in fear that he may have attack any time as a result he feels
stressed and restless most of the time which is causing a lot of distress to family as
well. He is the only breadwinner of the house. he has done treatment from many
doctors but nothing helped
• Mode of onset: insidious
• Course of illness: fluctuating
• Progress of illness: static
• Duration of illness: 5 years
• Predisposing factors: Being in closed places or alone at home
• limiting factors: when patient goes to open space, deep breath, rub his hands
and drink water
• Associated disturbance: lack of sleep, restlessness and stress
• perpetuating factors: anxiety in psychological factors
 PAST PSYCHIATRY AND MEDICAL HISTORY
NIL

TREATMENT HISTORY
Patient is currently not taking any medication. But in the past he had gone to many doctors to treat his physical
symptoms but nothing had helped him.

BIOLOGICAL FUNCTIONING
Sleep: client is not sleeping well from two weeks.
Appetite: normal
Energy: Active

NEGATIVE HISTORY
There is negative history of heart disease, high blood pressure and diabetes
 FAMILY HISTORY
The client’s mother is a PRINCIPAL and his father has
retired from his business as he is not keeping well. He
has two elder brother and they share a good bond. The
client has a son who is pursuing his higher education
from USA.
 PERSONAL HISTORY
Birth and development history: SINCE BOTH PARENTS WERE WORKING,HE WAS ALONE AFTER SCHOOL HOURS.

Behavior during childhood

The client stated that he had always been anxious growing up. He used to worry a lot during GOING TO SCHOOL & exams and would not be able to sleep
and eat properly. He used to be introvert child and had trouble talking with strangers. He described himself as a shy person. He didn’t have many friends but he
shared close bond with few people.

Academic History:
Client is graduate. He didn’t have much interest in studying as a result he joined his family business after UG. He liked playing cricket when he was in school.

Sexual history:

comfortable
 Premorbid personality

The client is introverted and

anxious person. He is spiritual.
he has difficulty bonding with people.
 MENTAL STATUS EXAMINATION

GENERAL APPEARANCE & BEHAVIOUR:

Appearance is neatly dressed. The client has touch with the surrounding.
Gait and gesture is normal. Rapport could be established and has a positive
attitude towards examiner.

MOVEMENT AND BEHAVIOUR:

The psychomotor movement is normal.
 SPEECH:
Speech is normal. The intensity / Tone is normal and Productivity is also
normal. The client’s speech is coherent and goal directed. Rate of speed is
normal and there is no pressure or poverty of speech is observed.
 MOOD / AFFECT:
• Subjectively: “I am worried”
• Objectively: The client is concerned about his health.
The depth and the intensity of the affect is normal. Mood is observed as congruent to the
thought, communicable and appropriate to the situation.
THOUGHT:
Content- the client had preoccupation about fear of closed spaces.

PERCEPTION:
No perceptual disturbances is seen from the client
 COGNITIVE FUNCTIONS:
• The client is oriented to time, place and date
• Attention & Concentration is aroused and sustained
1.Memory:
• Immediate memory: intact
• Recent memory: intact
• Remote memory: intact
2.Abstraction:
• Similarities: adequate
• Differences: adequate
• Proverb: adequate
3. General fund of knowledge: adequate
4. Judgment:
• Personal: intact
• Social : intact
• Test: intact
 5.INSIGHT:
good- true emotional insight: emotional awareness of the motives and feelings of illness which leads to
changes in behavior or lifestyle
6.DIAGNOSIS:
• The patient was diagnosed with Claustrophobia , The patient exhibit symptoms of hot flashes, panic attacks,
tension, sweating, nausea and fainting.

7.TREATMENT PLAN:
• CLIENT WAS APPRECIATED FOR ALL THE GOOD THINGS. The client was ASKED TO VISIT
PSYCHIATRIST WHO prescribed medicine to reduce the symptoms of anxiety. Psychiatrist advised him
to start psychotherapy / counselling as soon as possible. Doctor advised him to come again after two weeks
after taking medicies and meeting the counseler.
 One of the follow up session
SEVEN COLUMN THOUGHT RECORD

How
Much Do
What Evidence Do You You Still
What Evidence Do You What Other Perspective
Identify your Identify automatic Have To Believe
Event Have To Support This You
mood (%) thoughts or images Support This Alternative Your
Thought? Can Take On This?
Perspective? Initial
Thoughts?
(%)

That there could be some I haven’t heard anyone

I feel that lift will stop Once when I went to mall
technical issues and it rarely dying inside the lift because
Going in and I would faint. I feel the lift power went off and
90% happens. it was crowded or 60 %
lift like I will die in lift stopped for 2
Even if it happens that power went off for few
lift. minutes
does not mean I will die of minutes
suffocation .
 TREATMENT PLAN
Future treatment plan is to give exposure therapy to client after a couple of sessions. It s a type of
behavioral therapy that is designed to help people manage problematic fears. Through the use of
various systematic techniques, a person is gradually exposed to the situation that causes them
distress. The goal of exposure therapy is to create a safe environment in which a person can reduce
anxiety, decrease avoidance of dreaded situations, and improve one's quality of life.
DO SYSTEMATIC DESENSITIZATION
EXPOSSURE THERAPY
 FIRST SESSION
HE IS TRAINED IN JACOBSON’S PROGRESSIVE MUSCLE
RELAXATION?
HE WAS TRAINED IN WRIST BAND TECHNIQUE.
HE WAS TRAINED IN ONE MINUTE MINDFULNESS.
CLIENT WAS WALKED THROUGH VISUAL ALONENESS
FEW MINUTES. THEN THE TIME WAS INCREASED.
CLIENT WAS TOLD THAT HE WILL BE LEFT IN THE COUNSELING
ROOM FOR 5 MINUTES.
 HIT WRIST BAND EVERY TWO
MINTUES TO COME TO MINDFULNESS
THEN DO ONE MINUTE MFN
HE WAS ASKED TO DO RELAXATIN
EXERCISE
WHEN HE FEELS / STARTS TO FELL
ANXIETY
THE TIME LIMIT INCREASED TO 10
MINUTES
HE WAS GIVEN HOME WORK AND DO
THOUGHT RECORD
TRY TO WORK ALONE IN KITCHEN

MEETING AFTER TWO DAYS

 Summary:
THE TREATMENT HELPED THE CLIENT TO COME OUT OF THE
PHOBIA SLOWLY.

AFTER THREE SESSION, HE AS ABLE TO GO ALONE TO PLACES

TO HELP HIM WITH RELAPSE PREVENTION, MEETING FIXED

AFTER TWO WEEKS
 Bipolar disorder, formerly called manic
depression, is a mental health condition that
causes extreme mood swings that include
emotional highs (mania or hypomania) and lows
(depression).
 HYPOMANIA
Hypomania is a condition in which you display a revved up
energy or activity level, mood or behavior. The new “energized
you” is recognized by others as beyond your usual self.
Hypomania is a less severe form of mania, and both are
commonly part of bipolar disorder. Treatments include
psychotherapy, medication and self-care strategies.
 CASE STUDY- III (Bipolar affective disorder, hypomanic)

SOCIO-DEMOGRAPHIC DATA:

• Name: Mr. raju

• Age: 26
• Marital status: unmarried
• Gender: Male
• Occupation: Student
• Education: BBA
• Religion: Hindu
• Mother tongue: Hindi
• Location of residence: Bangalore
• Socioeconomic status: Upper
• Informant: father and uncle
12.Reliability: Reliable and consistent but inadequate
 CHIEF COMPLAINTS

According to the patient:

“I have no problem. My mind is super fast and no one can match it.”

According to the informant:

“he has become very aggressive and started abusing people. He had fights with his
friends and brother. He thinks that he is very intelligent and look down on others.”
 HISTORY OF PRESENT ILLNESS
The onset of the illness is acute. The client was apparently well a week ago. Three days before he got to know that he
cleared his entrance exam in IIM- Ahmedabad. He had been very ecstatic about it. Later in the evening he got aggressive
to his younger brother who jokingly said that he may have cheated in entrance exams. He responded him saying that his
mind is super fast and he does not cheat like he does.

Next day while returning back home at bus station station he abused his best friend and asked him to jump off in front of
bus. he even tried to push him.

Next day he again abused his friend and got aggressive he kept repeating that no one can match him. His father decided
to bring him to the hospital. Currently there is no significant change in his sleep pattern, he can maintain hygiene
however his energy level increased his appetite has decreased from past 2 days.
1.PAST PSYCHIATRY AND MEDICAL HISTORY
• The patient does not have any kind of past illness/psychiatric illness
Treatment History-

2.TREATMENT HISTORY
• NIL

3.BIOLOGICAL FUNCTIONING
• Sleep: client has not slept from 2 days
• Appetite: decreased
• Energy: very Active
 FAMILY HISTORY

The patient family is a nuclear family. His father is a bank

manager and brother is doing his graduation. Family
atmosphere is good. The patient financial status is also good.
 PERSONAL HISTORY
• 1.Birth order: first born, he has one younger brother.
• Birth and development history:
-Birth history was normal, Birth cry was present, Birth weight 2 kilo, Developmental milestones
achieved before handed, no emotional or physical problems were present in childhood.
3.Behavior during childhood
• The patient was good in school and used to score good marks. He had many friends growing up
and is an extrovert.
4.Sexual history
Not elicited
5.Premorbid personality
The patient was extrovert and had many friends, he never showed any kind of resistance earlier or
aggressiveness
 MENTAL STATUS EXAMINATION
GENERAL APPEARANCE & BEHAVIOUR:
He was good wearing a check shirt and pant, hair was properly made well dressed and
groomed, Behaviour was restless was wringing his hands and the patient was
uncooperative, hyperactive, restless but well dressed. Attitude towards examines-
uncooperative, Rapport could not be
established

MOVEMENT AND BEHAVIOUR:

Agitation was present and the patient was constantly moving his hands.
1.SPEECH:
• Rapid, pressure of speech was observed productivity–high
• Reaction time was decreased

2.MOOD / AFFECT:
• Mood - irritable, euphoric
• Affect- broad–congruent with mood

3.PERCEPTION:
• No perceptual disturbances are seen from the client

4.THOUGHT:
• Content- Ideas of grandiosity, Form- flight of ideas, rapid thinking, tangentially (where the patient does
not come to the point)
 COGNITIVE FUNCTIONS:
• The client is oriented to time, place and date
• Attention & Concentration is aroused and sustained
1.memory:
• Immediate memory: intact
• Recent memory: intact
• Remote memory: intact
2. Abstraction:
• Similarities: adequate
• Differences: adequate
• Proverb: adequate
3.General fund of knowledge: adequate
1.JUDGMENT:
• Personal: intact
• Social : intact
• Test: intact

2.INSIGHT:
• Level 1 - complete denial of the illness

3.DIAGNOSIS
• The patient was diagnosed with bipolar affective disorder, current episode
hypomanic. The patient exhibited symptoms of increased energy and activity,
talkativeness, decreased need for sleep, irritability and currently experiencing
hypomanic episode.
 TREATMENT PLAN
He was prescribed mood stabilizers. He was asked to come after a week. Based on his
condition he will be given various psychosocial treatments such as cognitive behavior
therapy, interpersonal therapy etc.

Following are the treatment plans which are helpful for bipolar patient.

1.Medication – Medication is the cornerstone of bipolar disorder treatment. Taking a

mood stabilizing medication can help minimize the highs and lows of bipolar
disorder and keep symptoms under control.
 2.Psychotherapy – Therapy is essential for dealing with bipolar disorder and
the problems it has caused. Working with a therapist, patient can learn how to
cope with difficult or uncomfortable feelings, manage stress, and regulate
mood.

3.Education – Managing symptoms and preventing complications begins with

a thorough knowledge of illness. The more patient and his family know about
bipolar disorder, the better they will be able to avoid problems and deal with
setbacks.
 4.Lifestyle management – By carefully regulating lifestyle, patient can keep symptoms
and mood episodes to a minimum. This involves maintaining a regular sleep schedule,
avoiding alcohol and drugs, eating a mood-boosting diet, following a consistent exercise
program, minimizing stress, and keeping sunlight exposure stable year-round.

5.Support – Living with bipolar disorder can be challenging, and having a solid support system
in place can make all the difference in outlook and motivation of the patient. The support of friends
and family is invaluable.