CASE DISCUSSION

Presenter: Aqsa Ather

Objective

 Diagnostic clarification and discussion of findings of

psychological assessments
Socio- Demographic details

• Name : Mr. Rather

• Age : 32
• Sex : Male
• Education : Educated up to 7th standard
• Marital status : Married
• Religion : Muslim
• Place : Rural

• Informant : Wife of the patient, sister-in-law, brother-in-law

• Information: The information provided is partially reliable.
Chief Complaints:

• Irritability
• Saying multiple times, “I will die”

History of:
• Repetitive thoughts that he will die
T.D.I = 4 Years
• Low mood Exac.= 3months

• Feelings of guilt
• Repetitive checking himself on mirror
• Increased appetite
• Excessive use of water
o Predisposing factors: Personality vulnerability (possible cluster-c traits),
socioeconomic factors.

o Precipitating factors: surgical event (hemorrhoidectomy), surgeon’s

reassurance perceived as invalidating, occupational disruption, verbal criticism by
family members

o Perpetuating factor: poor medication compliance, family conflict and

expressed emotions.

o Onset : insidious

o Course : continuous

o Progress : deteriorating
History of Present Illness:

The patient initially presented with intermittent rectal bleeding, perianal pain during
defecation, and occasional mucous discharge. As the symptoms worsened, and he
underwent surgery for haemorrhoids which was reportedly successful. However,
following the surgery, he developed persistent and intrusive thoughts that the
procedure had failed and that he would soon die due to complications. He frequently
expressed these thoughts to his family, despite reassurance.
He exhibited excessive health related anxiety, visiting the operating surgeon
multiple times a day for weeks, and remained unconvinced despite repeated
explanations that the surgery was successful. This preoccupation led to significant
functional impairments; he stopped working and became dependent for financial
help from relatives.
This was followed by patient complaining of low mood, fatigue. He had increased
appetite, consumed meals more frequently than before, and demanded large
amounts of tea (20-30 cups/day). Sleep, however, remained unaffected.
The patient also developed repetitive behaviours, including excessive use of water
for bathing and washing, frequent mirror checking (15-20 times/day), and concerns
about changes in his physical appearance (like feeling darker skin tone, weaker, and
less attractive). Following psychiatric intervention at JVC hospital and treatment with
Psychotropic medications (records unavailable), there was an improvement in his
mood and obsessive thoughts. He resumed work and began managing household
finances. However, he discontinued medication and experienced a relapse, with
recurrence of obsessive thoughts, depressed mood, functional decline.
Over the past three years, compulsive behaviors (repetitive washing, mirror checking)
persisted. More recently, he expressed intense guilt about his financial inadequacy
and family responsibilities. He began saying repeatedly that he would die soon. These
statements occurred hundreds of times a day.
In the last few days before admission, psychosocial stressors escalated following a
police complaint by his wife due to his inactivity. This led to increased distress and
suicidal ideation, prompting his family to bring him for psychiatric evaluation at
IMHANS.
Negative History:

• No history of head injury

• No history of psychotic symptoms (hallucinations, delusions)
• No history of mania or hypomania
• No history of substance use
• No past psychiatric illness prior to onset
Family history:

?ID
Family History (contd…)

Patient was out of consanguious marriage.

He is 3rd in birth order with 2 brothers and 1 sister
H/O : ID? In younger sister
Personal History:

Patient was born out of consanguineous marriage at term with no

antenatal, natal or postnatal complications.
Patient cried immediately after birth.
There has been delay in motor movements.
Diagnostic Formulation:

A 32 year old male, labourer by profession, from rural background, belonging to lower
socio-economic status, premorbid personality of frequently being anxious and shy. He
was brought by his sister-in-law and brother-in-law with chief complaints of irritability,
saying multiple times that I will die from past 3 months with T.D.I = 4 years.
previously functioning well, developed persistent intrusive thoughts centered around
the fear of dying due to the successful haemorrhoid surgery. These thoughts are
excessive, irrational, and repetitive, accompanied by compulsive checking (touching
surgical site), repeated reassurance seeking, mirror checking, water sprinkling
despite reassurance, he is unable to stop these behaviours. Over time, he developed
significant functional impairment, increased appetite, and depressed mood.
Symptoms approved with medication but recurred due to non-compliance.
Provisional Diagnosis:

1. Obsessive- Compulsive Disorder, with poor insight

• Points in favor :
 Intrusive, repetitive thoughts (I’ll die from surgery).
 Compulsions : repetitive reassurance seeking, checking, water
sprinkling.
 Poor insight : persistent belief despite reassurances and normal
surgical outcome
 Functional impairment and distress
2. Major depressive disorder

• Points in favor:

 Persistent low mood, fatigue, guilt, suicidal ideation.

 Appetite changes (increased), social withdrawal
 Stressor related to psychosocial stress (financial issues, marital strain)

• Points against:

 Depression appears to be secondary to OCD symptoms and life stressors

3. Illness anxiety

• Points in favor:
 Persistent fear of a serious health consequence (dying from injury)
 Excessive health-related behaviors- frequent reassurance- seeking
 Anxiety surrounded around health
 Continues even after medical reassurance.

• Points against:
 Presence of OCD features
o Intrusive, repetitive thoughts.
o Compulsions/rituals beyond health checking
 Preoccupation is not just about illness- includes body image issues, guilt
 Insight is poor, more aligned with OCD spectrum
 Psychological Assessments :

Tests Administered

• Yale Brown Obsessive Compulsive Scale (Y-BOCS)

• Hamilton Scale for Depression (HAM-D)
• MILLONS CLINICAL MULTIAXIAL INVENTORY (MCMI)
• DRAW A PERSON TEST (DAPT)
• RORSCHACH INKBLOT TEST (RIBT)
• SHORT HEALTH ANXIETY INVENTORY
• The Brown Assessment of Beliefs Scale (BABS)
 General Test Behavior:

• Patient was cooperative but anxious, repeatedly asking whether he was doing it
“right”.
• Patient appeared distracted during the administration of the test.
• Repeated reassurance-seeking, he frequently sought validation and reassurance
from the examiner.
• Emotional lability, he cried, appeared sad during parts of the assessment.
Y-BOCS

THEMES ELICITED :

• Somatic obsessions
• Cleaning compulsions
• Checking compulsions

Y-BOCS Scores

 Obsessions subscale : 14/20

 Compulsions subscale: 9/20

 Total score: 23/40, indicates moderate severity.

HAM-D

The patient’s total HAM-D score was found to be 22 falls within the severe
depression range. This indicates significant depressive symptomatology
with marked functional impairment and distress.
MCMI-3

Validity Indices:
•X (Disclosure): 78 – Suggests the client was relatively self-revealing, potentially
exaggerating distress or endorsing symptoms more than usual. This may enhance
the visibility of clinical symptoms. Interpret with some caution due to elevated self-
disclosure.
•Y (Desirability): 47 – Within normal limits; suggests little attempt to present in an
overly favorable light.
•Z (Debasement): 85 – Elevated. Indicates the client may feel overwhelmed by
emotional problems and is portraying themselves in a highly negative light, possibly
reflecting genuine distress or a cry for help.

Clinical Personality Patterns

•Dependent (94) – Clinically Significant Elevation

The client shows strong dependent traits, likely relying heavily on others for
emotional support and decision-making. They may fear abandonment, avoid
confrontation, and exhibit submissive behavior. This pattern often reflects low self-
confidence and a need for constant reassurance.
Negativistic (81) – Moderate Elevation
Suggests a passive-aggressive interpersonal style. The client may experience internal
conflict between dependence and resentment, leading to irritability, indirect
resistance, and moodiness. They may appear cooperative while subtly expressing
defiance or dissatisfaction.

Severe Clinical Syndromes

•Anxiety (89) – Clinically Significant

The client likely experiences chronic worry, tension, and fearfulness. Symptoms may
include restlessness, hypervigilance, and somatic complaints. This elevation aligns
with generalized anxiety disorder or persistent anxiety traits.

•Somatoform (92) – Clinically Significant

Indicates a strong likelihood of physical symptoms (pain, fatigue, gastrointestinal
distress, etc.) without a clear medical explanation. These may be expressions of
psychological distress and are often resistant to medical reassurance.
•Dysthymia (106) – Very High Elevation
Suggests pervasive low mood, chronic sadness, low energy, and pessimism. The
client may appear hopeless and self-critical, showing symptoms consistent with a
persistent depressive disorder. This is one of the most prominent features in the
profile.

•Major Depression (82) – Clinically Significant

Supports the presence of major depressive symptoms such as anhedonia, guilt, and
suicidal ideation.
DAPT:

Positive findings:
Presence of dependency/ helplessness, inadequacy, evasion of body problems, lack
of impulse control.

RIBT:

The patient provided only 12 responses, which falls below the required responses
(14) for reliable interpretation. Additionally, patient did not participate in the
Enquiry phase, due to which the protocol is deemed to be invalid for interpretation.
SHAI:

The patient scored 22 on the SHAI, indicating presence of significant health-

related anxiety. The score falls within the moderate range, suggesting that the
patient has a heightened preoccupation with physical health and fears serious
illness, despite medical reassurance.

BABS:

The patient scored 13 indicates poor insight into the beliefs.

“The Puzzle of The Mind”

• The first clue: What’s driving the distress?

 Are his beliefs about illness fixed, and not open to reason?
Yes?
You’re headed towards delusional disorder
But: he shows some insight, and is distressed by the thoughts, and performs
rituals.
Not a delusion – keep going…

• The rituals reveal themselves

Are these obsessions and compulsions?
Yes?
The plot thickens- welcome to the realm of OCD
 Repeated checking
 Excessive washing
 Mirror checking
 Intrusive thoughts about death
 Poor insight present
 Primary suspect identified : OCD with Poor Insight

• A red herring: is this illness anxiety?

Is he just afraid of being ill, with no real compulsions?

Possibly but, unlike classic illness anxiety disorder, he doesn’t just fear- he acts;
checks, cleans

• The Shadow of Sadness:

Are mood symptoms like guilt and hopelessness the center of the story?

 They’re here, but are side characters, not the main plot.
 Likely secondary Major Depressive Disorder- comorbid, not primary.

• Final Twist- Psychosis?

 No hallucination
 No thought disorder
 No cognitive deficits
So, Final Verdict (Final Diagnosis):

Primary: Obsessive Compulsive Disorder with Poor Insight

Comorbid : Major Depressive Disorder (Secondary to OCD)