PSYCHO-DIAGNOSTIC REPORT- 02

SOCIO - DEMOGRAPHIC DETAILS:

Name: S
Age: 32 years
Gender: Female
Religion: Hindu
Education: BA
Occupation: Housewife
Socio-economic Status: Middle Class
Marital Status: Married
Family Type: Nuclear family
Address: Ajmer, RJ

INFORMANT’S DETAILS
The information was
presented by patient’s
husband and her father.
The information provided
was found to be reliable
and adequate.

CHIEF COMPLAINTS :
As per the informant,
Low mood 1.5month
Fatigue 1.5month
Loss of interest in work 1month
Death wishes 2weeks
Apprehension about future 1month
Tremors in hands and legs 1 month
Breathlesness 3 weeks
Reduced sleep and appetite 2 months

As per the patient,

“Mann ukhda sa rehta hai, jee nahi lagta iss
ghar me”
”mujhse koi kaam nahi hota hai, kaafi thakan
rehti hai”
“Haath per toote toote rehte hai”
“Mann nahi karta kahi jaane-aane ka, kisise
baat karne ka”
“Mera aur baccho ka ab kya hoga, mujhe
samajh nahi aara”
“Mujhe apne husband pr vishwas nahi, kaafi
tanaav rehta hai sir dard karta hai”

HISTORY OF PRESENTING ILLNESS

(HOPI):

Onset: acute
Course: continuous
Progress: deteorating
Predisposing factor: none
Precipitating factor: Husband’s extramarietal activity
Perpetuating factor: environment and surroundings
The patient is a 32-year-old married woman who was reportedly functioning well in her personal
life until around two months ago, when a distressing event happened and it resulted in beginning of
her symptoms. According to the patient and her family, the onset of symptoms was sudden and
linked to the traumatic experience.

One day, upon coming home from the market, the patient felt that her husband was unusually tense
and jumpy. Upon entering the living room, she heard a woman's voice. When she asked her husband
about it, he was defensive and attempted to divert her attention. She did not feel right, when she
searched the house, discovered another woman hiding in their bedroom closet. In shock, the patient
accused her husband and had a fight, who at first was also aggressive, did not agree but then
confessed to the extramarital activity.

Since the day, the patient was not herself. She started presenting with chronic low mood,
tearfulness, and reduced emotional reactivity. She would remain in bed for hours exhausted and
tired with minimal activity. Her appetite and sleep decreased considerably. She complained of
inattentiveness to do household work and would frequently have mind wandering here and there.
She discontinued interaction with family and friends and avoided social interactions, preferring to
be alone.
She also showed signs of hopelessness, saying comments like "mere jeene ka koi matlab nahi raha"
and death wishes, although she denies active suicidal plans. She also started experiencing—
constantly reporting chest tightness, trouble breathing, muscle tension, headache, and observable
tremors in her hands and legs. She has also built severe trust problems, particularly towards her
husband, and tends to be apprehensive of what might happen in future for her children and herself.
The husband still does not show any efforts in making her feel safe whereas he himself showed
aggressive behavior towards her during the interview. The symptoms have been persistent and had a
strong impact on her daily functioning, leading to seeking psychiatric intervention by the family.

NEGATIVE HISTORY :

• N/H/S of brain fever, head trauma or any surgeries related to the brain, LOC,
seizure and syncope.
• N/H/S of use of any psychoactive substances.

• N/H/S of some entity taking over his body or his feelings, actions and
thoughts are under the control of someone else.
• N/H/S of loss of integration, loss of memory, bodily sensations, loss of
awareness, or twitching sensations.
• N/H/S of frequent visits to doctors despite no evidence, frequently changing
complaints.

• N/H/S of hearing his own thought aloud, someone putting thoughts into his
mind, thoughts being drawn out of his mind, other knowing his thoughts
without being told or any other medium, feelings his action, thoughts or
feeling was under control of someone else.

• N/H/S of any sexual dysfunction.

TREATMENT HISTORY : negative

PAST PSYCHIATRIC ILLNESS : Negative

ANY PAST AND PRESENT ILLNESS : No

abnormalities were found.
FAMILY HISTORY :
The patient lives with her nuclear family (1 son and husband). The home
environment has not been cordial and the patient hasn’t been maintaining
well with her family. The family has been really concerned apart from
husband regarding the health of the patient. Absence of any overt
psychiatric conditions in the family history.

Family members have not reported any substance consumption. The

familial dynamics does not suggest a supportive environment, the
relationship between her and husband are not good contributing to a
negative familial atmosphere.

PERSONAL HISTORY :

Birth and early development : The patient was born through a full-term,
normal delivery, marked by a healthy birth cry and devoid of any
complications. Her prenatal development and birth process were described
as uneventful. During the antenatal and perinatal periods, there were no
reported complications or incidents.
Throughout her early development, she met all milestones at the expected
times, demonstrating a consistent progression in physical, cognitive, and
social abilities.
Presence of childhood disorders : No abnormalities found
Home atmosphere in childhood and adolescence :The patient has been
maintaining well in the different environments and a healthy relationship
with parents and child but not with spouse due to which they indulge in
frequent fights. This also possesses negative impact on the child.
Scholastic and extracurricular activities : The patient has been an
average student and has been showing interest in school and has been
maintaining healthy relationships among fellow mates. She used to score
above 60% in most of the subjects. The patient was not so active in co-
curricular activities.

Vocational/ Occupational history : Pt. shows a healthy and responsible

nature at home taking care of household chores and kid’s responsibilities.

Sexual history: Pt got to know about sex, porn in class 7th through her
friends which she later discovered more through movies and pornography.
At first she was disgusted by the idea but later understood the concept in
her biology class 9th standard. She got married but the physical intimacy
never came with satisfaction. She used to divert the topic with husband
and did not feel the urge to initiate the act.

Marital history: age at marriage: 25yrs, parental concent was there,

patient reported that she does not have a healthy relationship with husband,
not adequate.

Menstrual history: Regular, Menarche: 13yrs. The patient was well

informed about it by her mother in the past.

Forensic history : Not applicable

General pattern of living : The patient has been maintained well and
adjusting in different situations of living. Currently pt lives in her own
independent house, managing all the chores, staying active and does not
have any house help.

PREMORBID PERSONALITY :

1.Social relations : The patient exhibited outgoing behavior in social

settings, relationships with friends and family have been well maintained
and responsible behavior has been displayed. Dependant behavior towards
husband.
2.Intellectual activities, hobbies and use of leisure time : The patient
used to play with son, watch movies and showed interest in cooking.

3.Predominant mood : The patient was able to maintained a calm

demeanour, relaxed but displaying anger, crying when met with un-
favourable or stressful situations. She approached life with a optimistic
attitude. While she used to sometimes worry, she generally remained
resilient in the face of challenges.

4.Character :
a)Attitude to Self : The patient says that she has been focused on self and
has been hardworking as well as focused on household chores, kid and her
personal health. She is able to be a good mom and daughter-in-law,
fulfilling all the duties. She says she is resilient and will work to become
independent.

b)Attitude to Work and responsibility : The patient approached her

responsibilities with diligence and determination. Despite occasional
setbacks, she remained committed to achieving her goals and fulfilling
obligations.

c)Interpersonal relationship : The patient has been maintaining

relationships in a healthy manner and has been really close with her sisters
and also had friends in her neighborhood with whom she organises get-
together every month.

d)Standards in moral, religious and health matters : The patient held

herself to high moral standards, prioritizing honesty, integrity, and
compassion in her interactions with others also taking care of family. She
does very little for her own health.
e)Energy, initiative : The patient has been energetic in her life, likes her
friends and initiates conversations.

5.Fantasy : None

6.Habits : No harmful habits found.

MENTAL STATUS EXAMINATION :

General appearance :
The patient was kempt and tidy and had dressed appropriately to her age
with leptosome body-built. Touch with surroundings was present and
dressed appropriately. Eye contact was maintained during the whole
session.

Attitude towards examiner and rapport:

He was cooperative and rapport was easily established, patient was co-
operative during the whole session.

Motor behavior:

The patient was a bit restless.

Speech:
The patient's speech was audible characterized by normal pitch and a soft
tone. She exhibits normal reaction time in her responses, suggesting well
versed thoughts. There was coherence and relevance in her speech content,
tensed up manner of relating.

Higher Cognitive Functioning:

Attention and concentration: Attention aroused and sustained.

Orientation: The patient was oriented for time, place and person.

Memory:

● Immediate: Intact
● Recent: Intact
● Remote: Intact
Abstract ability: The patient was able to comprehend the given proverbs.

Calculations, Intelligence and General Fund of Knowledge: No

impairment found. Average level of intelligence.
Mood and Affect:

Subjective: Interviewer: Abhi aapka mann kaisa hai? Reply: Thik hai.

Objective: The patient had euthymic mood, displaying adequate emotional

expression throughout the examination. Her mood appears anxious. Facial
expression reflected worry and irritability. Affect worse in morning.
Thought:

• Stream : No abnormalities found

• Form : No abnormalities found
• Possession : No abnormalities found

• Content: worry
“Mujhe samajh nahi aara hai ki kya hoga, ye sab kese sahi hoga.
Mujhe nahi lagta ki ye apni aadatein sudharenge. Baccha bhi hai
kya krungi mai”

Perceptual disorders:

There are no apparent hallucinations or perceptual disturbances noted

during the examination.

Judgment: Intact
Insight: Grade 3

Sample : Aapko kya lagta hai aapko kya bimari hai ?

Reply : mujhe dikkat inki vajah se hui hai aur shaaririk mansik dono ho
rahi hai.

DIAGNOSTIC FORMULATION:

Mrs. S is a 32-year-old married woman from Ajmer who began experiencing

emotional and physical distress after discovering her husband's extramarital affair
two months ago. Since then, she has shown signs of low mood, fatigue, social
withdrawal, poor concentration, trust issues, and worries about her future. She also
reports physical symptoms like headaches, tremors, breathlessness, and reduced sleep
and appetite. Her relationship with her husband remains strained, and she lacks
emotional support at home. During the assessment, she was cooperative and oriented
but visibly anxious and tense. Her thought process was coherent, and judgment was
intact, though her affect showed distress. She understands her emotional suffering
and attributes it to ongoing marital issues, which continue to affect her daily life and
well-being.

PROVISIONAL DIAGNOSIS:

Adjustment disorder; Mixed anxiety and depression

FINAL DIAGNOSIS :

Following Mrs. S’s case history, serial mental status examinations and
psychological assessments the Diagnosis of Adjustment disorder; Mixed
anxiety and depression.

ASSESSMENTS:
BDI: 12 (minimal)
HAM-A: 15 (mild)

MANAGEMENT:
• Provide a safe, non-judgmental space during sessions. Encourage involvement of a
supportive family member (e.g., her father) during early treatment.

• Safety planning in case suicidal thoughts intensify — regular monitoring and helpline
availability.

• Educate the patient and family about stress-related and trauma-induced psychological
symptoms. Begin Supportive Psychotherapy to help with emotional ventilation, validation,
and strengthening of coping skills.

• Introduce basic relaxation techniques (e.g., deep breathing, grounding) to reduce somatic
anxiety.

• Reintroduce social interactions slowly with trusted people (e.g., sister, father).

• Begin Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) or Interpersonal Therapy

to address betrayal trauma, low self-esteem, and hopelessness. Address trust issues, identity
disruption, and future fears in a structured way.
 • Only if the patient feels safe and ready, couple therapy may be introduced. Focus would be
on restoring trust, communication, boundaries, and decision-making about the relationship’s
future.

• If child is affected by family tensions, consider family counseling to ensure child’s

emotional well-being is not compromised.

GOOD PROGNOSTIC FACTORS:

• Insight is present — patient recognises her issues.

• Supportive family members (e.g., father).

• Willingness to seek help.

• Premorbid personality was resilient and socially well-adjusted.

• No past psychiatric illness or substance use.

BAD PROGNOSTIC FACTORS:

1. Ongoing marital conflict and lack of support from spouse.

2. Passive death wishes — risk of worsening if untreated.

3. Environmental perpetuation of distress — limited relief at home.

4. Low self-confidence and dependency on spouse.