PSYCHO-DIAGNOSTIC REPORT- 05

SOCIO - DEMOGRAPHIC DETAILS:

Name: MP

Age: 22 years

Gender: Male

Religion: Hindu

Educa on: BA LLB (2nd year)

Occupa on: student

Socio-economic Status: middle class

Marital Status: un-married

Family Type: Joint family

Address: Ajmer, RJ

INFORMANT’S DETAILS

The informa on was provided by pa ent and his brother. The informa on
provided was reliable and adequate.

CHIEF COMPLAINTS :

As per the pa ent,

Mann udas rhta h bhot zada -Low mood- 1 month

Kisi b kaam m mann nhi lagta- Loss of interest in work-1 month
Akela rhne ka mann krta h - Social withdrawal
Kisi kaam mai dhyaan nahi de paa raha hu - Reduced attention and
concentration- 2 weeks
Alcohol pi rha hu 4 mahine se week m kayi bar abi 1 mahine se roz hi pii leta
hu ek bottle tk - Alcohol consumption

HISTORY OF PRESENTING ILLNESS (HOPI):

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 Onset: Insidious

Course: Con nuous

TDI: 4 month

CDI: 1 month

Progress: Deteriora ng

Predisposing factor: not known

Precipita ng factor: Peer pressure

Perpetua ng factor: Consuming alcohol

The index patient was reportedly asymptomatic until about four months ago. He
shifted to Jaipur for college, was maintaining well in his routine and academic
life, pursuing his college studies without any significant difficulties. However,
during this period, he came under the influence of certain peers who engaged in
regular substance use. Gradually, due to peer pressure and poor social influence,
he began consuming alcohol and cigarettes occasionally, which soon escalated
into a daily habit. Over time, his alcohol consumption increased to nearly one
full bottle per day, accompanied by frequent smoking.

In the past one month, the patient began experiencing a noticeable decline in his
emotional and functional well-being. He reports persistent low mood, marked
disinterest in studies and college activities, and a desire to withdraw from social
situations. He avoids interactions, feels lethargic most of the time, and struggles
to focus or concentrate on academic tasks. He also reports a decline in sleep
duration and quality, along with a reduced appetite. These symptoms have
progressively interfered with his daily functioning and overall quality of life.

NEGATIVE HISTORY :

N/H/S of head injury, brain fever, urinary incontinence etc

N/H/S of seeing images, hearing voices, fixed belief that others are talking
about or plotting against etc
N/H/S of increased energy, excessive talkativeness etc
N/H/S of fear of losing out or getting an attack.
N/H/S of fear of going out in open spaces or fear of specific objects.
N/H/S of partial or complete loss of memory, immediate sensations or control of
bodily movements.
N/H/S of multiple, recurring and changing physical complaints.
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 TREATMENT HISTORY : No history present

PAST PSYCHIATRIC ILLNESS : No history present

PAST MEDICAL HISTORY: No history present

FAMILY HISTORY :

No History of psychiatric and medical illness was reported

The pa ent resides in a joint family with 3 brothers, mother and father. He live
with a lot of cousins. The home environment is described as warm and
nurturing. He shares a close bond with his family members, maintaining open
communica on and mutual trust. The family members are very educated as to
understand the situa on but suppor ve, o ering both emo onal and physical
care. The overall family dynamics re ect a harmonious and encouraging
atmosphere. There are no known psychiatric illnesses in the family. The
pa ent’s bothers are notably a en ve and concerned about his well-being.

PERSONAL HISTORY :

Birth and early development : The mother’s emo onal and physical state was
normal at the me of pregnancy. The pa ent was a full-term baby, delivery
took place in hospital without any complica ons. Birth cry was immediate,
weight was normal and he did not su er from any illness in the post-natal
period. His developmental milestones were achieved within the expected
meframe.

Presence of childhood disorders : No abnormali es found

Home atmosphere in childhood and adolescence : The pa ent demonstrated

good adjustment across various environments and maintained a healthy
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 rela onship with his family members. Till date he is able to share all his
thoughts and feelings with his brothers.

Scholas c and extracurricular ac vi es : The pa ent began formal educa on at

the age of 4, a ending an Hindi medium school. He was a well-performing
student, achieving 75% in his 12th grade and securing admission to a law
college. During his school years, he maintained posi ve peer rela onships,
exhibited an outgoing personality, and ac vely par cipated in co- curricular
ac vi es, par cularly in cricket and kabaddi.

Voca onal/ Occupa onal history : Healthy and responsible nature has been
showcased by the pa ent at home but not in college as he indulged in mal-
adap ve behaviors. He was able to study well, par cipate in sports ac vi es.

Sexual history : The pa ent got knowledge regarding sexual informa on when
he was 13 years of age through movies and then his friends later watched
pornographic movies masturba on was reported mul ple mes a week at the
beginning. He had a girlfriend when he was in 12th standard and the
rela onship was maintained well for 6 months a er which they separated due
to him moving to college and the discrepancies increased. He has never been
involved in a physical rela onship.

General pa ern of living : He currently resides in a at which he share with his

4 friends.

PREMORBID PERSONALITY :

1.Social rela ons : The pa ent exhibited extroverted behavior in social se ngs,
trusts people easily, rela onships with friends and family have been well
maintained and responsible behavior has been displayed.

2.Intellectual ac vi es, hobbies and use of leisure me : The pa ent

men oned that he liked to play kabaddi, cricket with friends, travelling.

3.Predominant mood : His predominant mood was open, talka ve and

cheerful. He had a stable mood and was able to express his feelings to his
brothers.

4.Character :

A)A tude to Work and responsibility : The pa ent had a posi ve a tude
towards himself. Has been focused on self and been hardworking. He
approached his responsibili es with diligence and determina on. He remained
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 commi ed to achieving his goals and ful lling his obliga ons. He was very
serious regarding his studies and securing a well paying job.

B)Interpersonal rela onship : The pa ent has been maintaining rela onships in
a healthy manner and has been really close with his brother and also had
friends in his neighbourhood.

C)Standards in moral, religious and health ma ers : The pa ent held himself to
high moral standards, priori sing family, health, and respec ng others. He has
been involved in religious prac ces since childhood.

D)Energy, ini a ve : The pa ent has normal level of energy.

5.Fantasy : No fantasy has been reported

6.Habits : No harmful habits reported

MENTAL STATUS EXAMINATION :

General appearance :

• Physical Appearance: kempt and dy

• Es mate of Age: Appropriate to age

• Body Build: Athle cs

• Touch with surroundings: Present

• Eye Contact: Maintained

• Dress: Appropriate

• Facial Expression: Furrows on the brows

• Posture: Hunched shoulders

A tude towards examiner and rapport: Co-opera ve, rapport was easily
established

Motor behaviour: Retarda on

Speech:
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 • Intensity: Audible

• Pitch: Modula ons were present

• Quality: Hoarse

• Tone: Low

• Tempo: Low

• Reac on Time: Increased

• Speed: Slow

• Relevance: Relevant to the ques on asked

• Coherence: Coherent

• Goal Direc on: Goal-directed

• Produc vity: Adequate

• Manner of rela ng: Normal

Higher Cogni ve Func oning:

A en on and concentra on: A en on aroused and sustained.

Orienta on: The pa ent was oriented for me, person, place.

Memory:

Immediate: Intact

Recent: Intact

Remote: Intact

Abstract ability: The pa ent was able to comprehend the given proverbs.

Calcula ons, Intelligence and General Fund of Knowledge: Average level of

intelligence

Mood and A ect:

Subjec ve:
Q:Abhi aapka mann kaisa hai?
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 A: thik nahi hai, accha nahi lagra

Objec ve: Dysphoric, xed mobility, full range, decreased reac vity,
appropriate communicability, appropriate a ect, diurnal varia on- worse in
morning

Thought:

● Stream : No abnormali es found

●Form :
Q- “Apko kya lagta hai ki ye situa on kese aai hai?”
A- Mene dosto ki baato mai aakr peeni chalu kardi, mujhe nahi karni chahiye
thi, mai kaa sahi tha pehle patani mai baato mai kese aa gaya aur r ruka
nahi, mene kaa galat kiya hai aur mera future barbaad ho gaya is aadat k
chakkar mai”

Impression: Depressive Rumina ons

● Possession : No abnormali es found

• Content :

Q- “kya lagta hai aapko kya chalra hai dimaag mai?”

A- “mujhe samajh nahi aara ki ye sahi kese hoga, mai kese roku iss aadat ko”

Q- “kya lagta hai aane vale samay k baare mai”

A-“ mai koshish karunga par lagta hai ki ye kese band hoga, itna asaan nahi hai
rse unhi logo se milna, frse yehi chij aayegi samne, mujhe sahi hone k asaar
kaa kam lagre hai”

Impression- Ideas of helplessness

Perceptual disorders: No abnormali es were found

Judgment: Intact

Insight:

Q : “Aapko kya lagta hai aapko kya hua hai ? Ye mansik roop se dikkat aai hai ya
sharirik?

A : “mujhe toh dimaag se hi lag hai, daaru ki vajah se dimaag par jor padra hai
aur tension ho hai”
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 Impression- Grade IV

DIAGNOSTIC FORMULATION:

Mr. MP, a 22-year-old unmarried Hindu male from a middle-class joint family, currently a
2nd-year BA LLB student, presented with complaints of persistent low mood, loss of interest
in academic and social activities, reduced concentration, social withdrawal, fatigue, disturbed
sleep, and appetite, ongoing for the past one month. The onset of alcohol use began
insidiously about four months ago under peer pressure, following which his consumption
gradually increased to one bottle per day. His functional decline became apparent in the last
month, marked by significant emotional distress and academic dysfunction. There is no prior
psychiatric, medical, or family history. His premorbid functioning was reported as well-
adjusted with healthy interpersonal relationships, good academic performance, and active
involvement in extracurricular activities. The primary stressor includes maladaptive peer
influence and separation from a structured home environment.

On Mental Status Examination, the patient was kempt, cooperative with furrows on the brows
and a hunched posture. His speech was relevant but slow and low in tone, with increased
reaction time. Mood was subjectively low and objectively dysphoric, with decreased
reactivity and diurnal variation. No abnormalities were noted in thought stream or perception,
though depressive ruminations and ideas of helplessness were present. Insight was partial
(Grade IV), and judgment was preserved. The symptoms appear to be perpetuated by ongoing
alcohol use and lack of structured coping mechanisms, despite a supportive family
environment.

PROVISIONAL DIAGNOSIS:

F10.24 M&B disorder due to use of alcohol, currently using the substance.
Predominantly depressive symptoms

MANAGEMENT:

• Detoxica on and Pharmacotherapy: If required, ini ate supervised detoxi ca on. Consider
medica ons for depressive symptoms a er detox. Monitor for drug interac ons and compliance.

• Establishing regular follow-up appointments to monitor medica on

e ec veness, assess symptom progression, and adjust treatment as needed.

• Encourage regular sleep hygiene, physical ac vity, and structured rou ne to

reduce autonomic symptoms (palpita ons, dizziness).

• Family and Social Interven

on: Involve family members in sessions to build a support system.
Recommend a temporary reloca on back to his home environment (if feasible) to reduce exposure
to maladap ve peer in uence.
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 • Psychoeduca on & Mo va on Enhancement Therapy (MET): Educate the pa ent and his family
about alcohol dependence and depression. Use mo va onal interviewing techniques to enhance
insight and readiness to change, especially since he shows Grade IV insight.

GOOD PROGNOSTIC FACTORS-

1. High Premorbid Func oning: The pa ent has a history of good academic
performance, social engagement, and healthy interpersonal rela onships,
indica ng strong baseline resilience.

2. Strong Family Support: He shares a close, emo onally open rela onship with
his parents who are a en ve and involved in his well-being.

3. Insight Present (Grade III): The pa ent recognises that his mental state is
being a ected, which increases recep vity to psychological interven ons.

4. Absence of Psychiatric Comorbidity: There is no history of psychosis,

substance use, or other major psychiatric illnesses in the pa ent or his family.

5. Early Iden ca on and Interven on: Symptoms have been iden ed early
(within 1 month of onset), allowing mely psychoeduca on and psychological
support.

BAD PROGNOSTIC FACTORS:

1. High daily alcohol intake (up to 1 bo le/day)

2. Con nued access to the same peer group promo ng alcohol use

3. Passive ideas of helplessness, low self-e cacy

4. Ongoing depressive symptoms, which may worsen relapse risk

5. Grade IV insight, which suggests awareness but limited control

6.Sleep Disturbance and Func onal Impairment: Emerging sleep issues,

academic disengagement, and loss of interest in previously enjoyed ac vi es
indicate moderate psychosocial dysfunc on.
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