IDENTIFICATION DATA
Name: Mr. R
Age: 28 years
Sex: Male
Education: Bachelor’s Degree in Computer Science
Occupation: Software Developer
Socio-economic status: Moderate
Marital status: Single
Informant: Self
Information: Adequate and reliable
PRESENTING COMPLAINTS DURATION
● Persistent anxiety: 4 months
● Social withdrawal: 4 months
● Irritability: 4 months
● Panic attacks: 2 months
● Difficulty sleeping: 4 months
Onset: Gradual
Course: Continuous
Progress: Deteriorating
Predisposing factor: Childhood bullying
Precipitating factor: Recent breakup with girlfriend
Perpetuating factor: Lack of social support
HISTORY OF PRESENT ILLNESS
Mr. R reports feeling anxious and withdrawn since his girlfriend ended their relationship four
months ago. Initially, he had trouble coping with the breakup, leading to persistent anxiety
and increased irritability. He began to isolate himself from friends and family, preferring to
spend time alone at home.
He describes episodes of panic that occur unexpectedly, characterized by shortness of
breath, palpitations, and an overwhelming fear that he might be losing control. These panic
attacks have made him avoid situations where he fears he might experience them, further
contributing to his social withdrawal.
Mr. R also reports sleep disturbances, often lying awake at night ruminating over his
situation. His concentration at work has deteriorated; he finds it challenging to focus on tasks
and is concerned about the quality of his work, which has been noted by his supervisor.
ASSOCIATED DISTURBANCES
● Social withdrawal
● Irritability
● Sleep disturbances
● Decreased appetite
NEGATIVE HISTORY
No history suggestive of hallucinations, delusions, or substance abuse. No significant
medical history noted. No previous psychiatric treatment or hospitalization.
TREATMENT HISTORY
No significant treatment history reported.
PAST HISTORY
No past history of psychiatric illness or significant medical issues.
FAMILY HISTORY
Family structure and functioning:
● Father (55 years): High school educated, employed as a government clerk, with a
history of anxiety but not formally treated.
● Mother (53 years): College educated, homemaker, reportedly very supportive of her
children.
● Younger sister (22 years): College student, close relationship with Mr. R.
The family is described as close-knit, but Mr. R often feels misunderstood by his parents
regarding his emotional struggles. There is no known family history of psychiatric illness.
SOCIO-ECONOMIC STATUS
Mr. R belongs to a middle socio-economic status. He earns approximately Rs. 40,000 per
month as a software developer, which supports him comfortably. His family does not require
financial assistance from him at this time.
PERSONAL HISTORY
Birth and early development:
Prenatal: Mother’s pregnancy was uncomplicated.
Perinatal: Normal delivery with no complications reported.
Post natal: Milestones were reached within normal limits.
Behaviour during childhood:
Mr. R faced bullying in school which affected his self-esteem. He was introverted and
struggled to make friends.
SCHOOL HISTORY
Mr. R attended a private school, where he was an average student but excelled in subjects
related to technology. He was shy but developed a small group of close friends during his
later school years.
OCCUPATIONAL HISTORY
After completing his degree, Mr. R worked in a startup for two years before transitioning to a
stable position as a software developer at a larger company. He reports feeling unfulfilled in
his job, especially after the breakup, leading to decreased productivity and motivation.
SEXUAL HISTORY
Mr. R became sexually aware at age 16 and has had a few casual relationships. He
expresses confusion and anxiety regarding intimacy and commitment.
USE AND ABUSE OF ALCOHOL, TOBACCO AND DRUGS
Occasional alcohol use, primarily in social settings. No tobacco or illicit drug use reported.
PREMORBID PERSONALITY
Attitudes to others in social, family and sexual relationships:
Generally caring but has difficulty expressing emotions. Tends to avoid conflict.
Attitudes to self:
Struggles with self-esteem, particularly following the breakup. He often feels inadequate and
worries about his future.
Moral and religious attitudes:
Not particularly religious but has moral values instilled by his family. He visits temples
occasionally.
Mood:
Typically calm but has become more anxious and irritable since the breakup.
Leisure activities and interests:
Enjoys coding and playing video games, but has lost interest in these activities due to
anxiety.
Fantasy life:
No significant fantasies reported.
Reaction patterns to stress:
Tends to withdraw and ruminate rather than confronting issues. Experiences increased
anxiety and irritability under stress.
Biological functions:
Reports disturbances in sleep and appetite; otherwise, no significant changes in excretory
functions.
