Cases handled (All names changed to maintain confidentiality)
1. Name:
D. Singh (Name Changed as this was a high profile case reported in press) (Medico Legal Case @ Sir J. J. Hospital);
The police arrested accused for abetment of suicide. Nearly a week after a family of four was found hanging, the police added rape to the list of charges they are investigating against the accused, who had been arrested earlier on the basis of suicide notes that alleged he had sexually assaulted one of the family members and driven them to suicide.
Age: 32 – 35 years
Gender: Male
Marital Status: Single
Occupation: Business
Date of Testing: 3/3/15
Place where Tested: Sir J. J. Hospital, Psychology Dept.
Presenting Complaint: Brought by the Police for testing
MSE:
Appearance: Neat and hygienic, decent grooming.
Movement and Behaviour: was normal.
Mood and Affect: Respectful, stable and subdued. He came across as open, sincere and honest in his responses. It did not appear that he was hiding any facts when being questioned. There appeared to be congruency in his affect.
Eye Contact: Initiated, sustained and maintained.
Speech: Spoke soft but tempo was normal to fast. Length of answers was appropriate. He had clarity in answering questions posed to him.
Emotional Status: Checked for hallucinations – answered No to questions whether he heard voices telling him what to do and if he felt that someone was talking about him. Checked for Delusions – Answered No to questions whether he felt people were after him or that his phone was tapped. Similarly the answers to Dissociation – as he was clear about where he was, who he was, what work he did.
When checking for obsessions, he did mention that he got recurring thoughts about his lover who had hanged herself in a family suicide pact, although he stated that they had broken off for over 6 months. He stated that he constantly pictured her with her new lovers.
Thinking and Perception: His thought processes were logical, sharp and clear. He did not volunteer any irrelevant details nor repeated any words and phrases and his thinking did not appear interrupted.
Memory – Long term and Recent: was intact.
Insight Level: (5) – Because he asked for help to combat his depression and sleeplessness he was experiencing in jail.
Tests Administered: Rorschach
Behaviour During Testing: The rapport was successfully established and he co operated very well.
Purpose of assessment: To assess his current levels of psychological functioning, more particularly whether he was suicidal or psychotic.
Diagnosis and Conclusion: (Testing of limits was not required as he got over 3 popular responses). From the ROR reading, it appears that this medico legal case is a normal to healthy individual, who is held by the police on charges of abetment to suicide and rape. However the ROR readings do not place him in disturbed category.
2. Name :
Sweta Ambre – (Personality Disorder)
Age: 30 years
Gender: Female
Education: Passed 10th
SES (Economic Status): Low income
Marital Status: Married and separated after 6 months of marriage
Occupation: Unemployed
Date of Testing: Thursday 23rd April, 2015
Place where Tested: Thane Mental Hospital
Presenting Complaint : Severe head aches on the left side of her head. She also has low tolerance to loud sounds.
Personal History: She admitted to having a difficult history growing up at her mother’s home and concurred with the file notings that she beats her mother on occasion.
MSE:
Appearance: Neat and clean
Movement and behaviour : Slow but deliberate
Mood and Affect: Appeared stable although she appeared in pain due to head ache. She appeared honest in answering questions and did not appear to be hiding information.
Eye Contact: Initiated, but not sustained.
Speech: Spoke soft and slowly. Length of answers was short but adequate. There was also adequate clarity in answering questions posed.
Emotional Status: Checked for hallucinations – answered No to questions whether she heard voices telling her what to do and if she felt that someone was talking about her.
Checked for Delusions – Answered No to questions whether she felt people were after her.
Similarly the answers to Dissociation – as she was clear about where she was, who she was.
Thinking and Perception: She did not volunteer any irrelevant details nor repeated any words and phrases and her thinking did not appear interrupted.
Memory – Long term and Recent: was intact.
Insight Level: (2) – Because she is aware that she has problems but blames the husband and her mother.
Tests Administered: TAT and DAP.
Behaviour During Testing: The rapport was successfully established and she co operated although because she was getting tired she kept asking when the process would end.
Purpose of assessment: To assess her personality, current levels of psychological functioning, more particularly to evaluate her patterns of thought, attitudes, and emotional responses to uncover her latent needs and presses.
Diagnosis and Conclusion: From the TAT and DAP is becomes apparent that Sweta, has borderline hostility and aggression, and interpersonal object relations towards her mother showing the extent to which she is emotionally affected by her and which in turn affects her relationships with others; and her ability to understand the complexities of human relationships; her ability to control aggressive impulses; self-esteem issues; and issues of personal identity. The eyes of the DAP indicate emotional bluntness and the out stretched arms and hands indicate a need to seek support and help. The torso is joined to the head without much of a neck which indicates a lack of adjustment by self to the outside world.
3. Name :
Uma Keshav Lingudkar (manic depressive - bi polar)
Age: 35 years
Gender: Female
Education: College drop out
SES (Economic Status): Low
Marital Status: Married. Deserted by husband.
Occupation: Former typist (when in college)
Date of Testing: 4th April, 2015
Place where Tested: Thane Mental Hospital (Admitted since past 4 years by her mother)
Presenting Complaint : No complaints currently – she is not in active phase.
Personal History : She was fond of her father, who would bring her gifts but who expired at age 65. She liked to dress up and was quite chubby, unlike now where she is “kurup zhala”. She has two sisters and one brother and a mother. She has one son age 18 years who is living with her mother presently. Her husband used to beat her on her thighs and her head and she suspected him of having an extra marital affair. She does not know why he left her.
MSE:
Appearance: Unkempt and dirty. Dress torn. Hair dishelved. When she sat on the floor, she was unaware that her legs were apart and she was indecently sitting before us.
Movement and behaviour : Slow and listless. Sometimes muttering and talking to herself.
Mood and Affect: Appeared to be in drug induced state. Her answers were contradictory at times. She was more interested in wanting to lie down and rest rather than be interviewed and tested by us.
Eye Contact: Not initiated, not maintained and not sustained.
Speech: Spoke in a disjointed manner, disconnected at times. She spoke very softly and slowly. Length of answers was short. There was also inadequate clarity in answering questions posed.
Emotional Status: Checked for hallucinations – answered No to questions whether she heard voices telling her what to do and if she felt that someone was talking about her.
Checked for Delusions – Answered No to questions whether she felt people were after her.
Similarly the answers to Dissociation – as she was clear about where she was, who she was.
Thinking and Perception: She did not volunteer any irrelevant details nor repeated any words and phrases and her thinking did not appear interrupted.
Memory – Long term : appeared to be intact. Recent memory was what was giving her trouble.
Sensorium : She was aware that she was at a mental institution and that she had been admitted by her mother. She was aware of time and space. She was unable to do basic addition nor count numbers forward or backward.
Insight Level: (1) – Because she was not aware why she was admitted and had no idea what her problem was
Tests Administered: ROR
Behaviour During Testing: The rapport was established but she got restless very quickly and she repeatedly gave similar to same answers on each ROR card “full pakhru”. She also kept asking when she could leave and when the process would end.
Purpose of assessment: To assess her current levels of psychological functioning.
Diagnosis and Conclusion: From the ROR responses it becomes apparent that Uma, has little touch with reality. Currently she was in a depressive state. She was on medication.
4. Name :
Teresa Fernandes - (Delusions of Grandiosity, Schizophrenic)
Age: 30 years
Gender: Female
Education: 10th Pass – St Joseph High School, Mazagaon
SES (Economic Status): Low - medium
Marital Status: Widow
Occupation: House maid
Date of Testing: 4/4/2015
Place where Tested: Thane mental Hospital
Presenting Complaint: Feeling Lonely
History of Past Illness: Used to hear voices in the past and was afraid that someone would capture her
Personal History: Alcoholic husband used to hit her as well as her father in law. She stays at nalasopara, with her two sons – Hansel and Ryan, before her admission to TMH. Her mother worked as an Aayah in Maasina hospital. She has 3 sisters and one brother who is working in Dubai. She too worked for 8 months in Dubai as a house maid. She mentioned that she liked everything neat and clean and we noticed during interview this trait when she would constantly clean her surroundings and herself.
MSE:
Appearance: Teresa was tidy in her appearance.
Movement and behaviour : She was bright and cheerful when we met her. Some of her movements were jerky and she would smile a lot. Her laughter too was borderline hysterical, but not prolonged.
Mood and Affect: She was happy to sit and talk to us as it alleviated her from her loneliness. She was interested in being interviewed and tested by us.
Eye Contact: Initiated, maintained and sustained.
Speech: Spoke in a disjointed, jerky manner, but it was high spirited. Length of answers was normal. There was also adequate clarity in answering questions posed.
Emotional Status: Checked for hallucinations – answered yes to questions whether she heard voices telling her what to do, but this was in the past, not recent.
Checked for Delusions – Answered yes to questions whether she felt people were after her. During interview stage she mentioned that many people and she herself felt Mother Teresa and herself were the same.
Checked for Dissociation – she was clear about where she was, who she was.
Thinking and Perception: She did not volunteer any irrelevant details nor repeated any words and phrases and her thinking did not appear interrupted.
Memory – Long term : appeared to be intact. Recent memory too was intact.
Sensorium : She was aware that she was at a mental institution and that she had been admitted by her mother. She was aware that it was Easter tomorrow. She was aware of time and space.
Insight Level: (1) – Because she was not aware why she was admitted and had no idea what her problem was
Tests Administered: ROR and DAP
Behaviour During Testing: The rapport was easily and successfully established. Purpose of assessment: To assess her current levels of psychological functioning. Diagnosis and Conclusion: The ROR and DAP responses indicate that Teresa may be suffering from delusion of Grandiosity which is also significantly brought out by the size of the head on the DAP. That she has scant touch with reality is also brought out by the DAP head which has frontal and side face drawn on same head. She was on Medication at the TMH.
5. Name :
Alka Patil (Paranoid Schizophrenia)
Age: 25 years
Gender: Female
Education: Basic Schooling
SES (Economic Status): Low
Marital Status: Separated
Date of Testing: Sat 11/4/2015
Place where Tested: Thane mental Hospital
Presenting Complaint : Alka complained that others were trying to harm her and she felt that she was being constantly watched.
Personal History: She lost her father at an early age and stated that she had been physically brutalized by her elder brother from age of 8 years continuously for three years after which he out station to look for employment. She stated that very often she entertained thoughts about self-harm as well as harming other people.
MSE:
Appearance: Unkempt and dirty. Dress torn. Foul body odour. Hair dishelved.
Movement and behaviour : Most of the time she was quite listless. Sometimes muttering and talking to herself.
Mood and Affect: Had an air of fear about her, looking over her shoulders
Eye Contact: Not initiated, not maintained and not sustained.
Speech: She tended to respond to queries with an unrelated answer, start sentences with one topic and end somewhere completely different, and said illogical things. Her answers were contradictory at times. Spoke in a disjointed manner, disconnected at times. She spoke very softly and slowly.
Emotional Status: Checked for hallucinations – answered Yes to questions whether she heard voices telling her what to do and if she felt that someone was talking about her.
Checked for Delusions – Answered Yes to questions whether she felt people were after her, especially she said that a neighbour was plotting to poison her.
Thinking and Perception: She appeared to have trouble concentrating and maintaining a train of thought.
Sensorium : She was not aware that she was at a mental institution.. She was not aware of time and space. She was unable to do basic addition nor count numbers forward or backward.
Insight Level: (1) – Because she was not aware why she was admitted and had no idea what her problem was.
Tests Administered: ROR
Behaviour During Testing: The rapport was established but she got restless very quickly and she repeatedly gave similar answers on each ROR card “Garbha Pishvi - womb”.
Purpose of assessment: To assess her current levels of psychological functioning.
Diagnosis and Conclusion: From the ROR responses it becomes apparent that Alka has little touch with reality. Currently she was in an anxious state. She was on medication.
Psychotherapy - for patients with paranoid schizophrenia, medications are the key part of treatment; however, psychotherapy is also important. The mainstay for individual psychotherapy is cognitive behavioral therapy, which helps the patient in two ways: identifying negative thoughts, and developing healthy coping strategies. Part of the psychotherapy process is to help the patient understand the symptoms of schizophrenia. Cognitive behavioral therapy can also help the patient cope with the stigma of paranoid schizophrenia.
Social and vocational skills training - this may help the patient live independently; a vital part of recovery for the patient. The therapist can help the patient learn good hygiene, prepare nutritional meals, and have better communication. There may be help in finding work, housing and joining self-help groups.
Compliance (adherence) - compliance or adherence in medicine means following the therapy regime (the treatment plan). Unfortunately, lack of compliance is a major problem for patients with schizophrenia. Patients can go off their medication for long periods during their lives, at enormous personal costs to themselves and often to those around them as well.
As a significant percentage of individuals go off their medication within the first 12 months of treatment, a life-long regimen of both drug and psychological/support therapies are important for treatment to be effective and long-lasting.
ECT (electroconvulsive therapy) - in this procedure an electric current is sent through the brain to produce controlled seizures (convulsion). It may be used on patients with severe symptoms or depression who either have not responded to other treatments or cannot take antidepressants. It is also sometimes used for patients at high risk of suicide. Experts believe that ECT triggers a massive neurochemical release in the brain, caused by the controlled seizure. Side effects may include short-term memory loss (usually resolves rapidly). It is important that the doctor explain clearly the pros and cons of ECT to the patient and/or guardian or family member.
6. Name :
Sarika More Thakur – (Conduct Disorder)
Age: 20 years
Gender: Female
Education : Till 9th
SES (Economic Status): Low
Marital Status : Married
Date of Testing : Sunday 12/4/2015
Place where Tested : Thane mental Hospital
Presenting Complaint : Laughs excessively – disturbs her mother – too much TV watching
Personal History : Resident of Ghatkopar, admitted by mother as patient feels she laughs too much all the time and her mother is disturbed by her behaviour since childhood. Recently she ran away on several occasions from her mother’s home and stayed out overnight. In the past she used to run away from school as the teachers complained to mother about her getting into physical fights with other children and bullying them; she said that when she was not allowed to watch TV, she would get very angry and throw severe temper tantrums; become defiant by not helping with house work. She has 2 children – a son who is studying class V and a daughter. She appears very close to her mother whom she says she misses in hospital. Husband is outstation for work so she has been staying with her mother with her two children.
MSE:
Appearance: Regular – nothing untoward to report.
Movement and behaviour : She appears to be hyper active.
Mood and Affect: Appeared stable but did keep asking when she would be discharged and that she was missing her mother and why was it that her mother had not come to get her home.
Eye Contact: Initiated, but not sustained for too long, nor maintained.
Speech: Spoke fast. Length of answers was adequate. There was also adequate clarity in answering questions posed.
Emotional Status: Checked for hallucinations – answered No to questions whether she heard voices telling her what to do and if she felt that someone was talking about her.
Checked for Delusions – Answered No to questions whether she felt people were after her.
Similarly the answers to Dissociation – as she was clear about where she was, who she was.
Thinking and Perception: She did not volunteer any irrelevant details nor repeated any words and phrases and her thinking did not appear interrupted.
Memory – Long term and Recent: was intact.
Insight Level: (2) – Because she is aware that she has problems but is not able to pin point what.
Tests Administered: TAT and DAP.
Behaviour During Testing: The rapport was successfully established and she co operated well.
Purpose of assessment: To assess her personality, current levels of psychological functioning, more particularly to evaluate her patterns of thought, attitudes, and emotional responses to uncover her latent needs and presses.
Diagnosis and Conclusion: From the TAT and DAP is becomes apparent that Sarika, has borderline hostility and aggression, and interpersonal object relations towards her mother showing the extent to which she is emotionally affected by her and which in turn affects her relationships with others; and her ability to understand the complexities of human relationships; her ability to control aggressive impulses; self-esteem issues; and issues of personal identity. The eyes of the female DAP indicate emotional bluntness whereas the male figure’s pin pointed eyes indicate hyper sensitivity. The out stretched arms and hands indicate a need to seek support and help. The torso is joined to the head without much of a neck which indicates a lack of adjustment by self to the outside world. Bared teeth in both figures would indicate high levels of aggressiveness and / or sexual abuse. Ears of DAP indicate a low tolerance at being corrected or guided.
TAT Testing on Sarika More:
Card No Patients Statements
1 Boy is singing “Bhagwan ka Geet” – He is thinking when will i go to school – In the past when his mother is close, he is happy, he cries when he is away from his mother – His mother and father had spent much money in sickness-
2 India Gate – mother takes child – works – river - father in law helping time to make meal – in future, ghar ka tension – both working and eating-
3 Mother telling daughter not to be truant – not to ask questions – Do her homework – keeps daughter in love – to get well – if in mental hospital mother will get sad -
4 Father in law bending – crying , come quick to save me, im in trouble – Girl wants to stay with mother and not to the cows -
5 She is not able to say – “pehle kya hua hoga”
6 “ladki ke saath ghatna hai” she was happy in the past in the house – this is outside the house – in future everyone will fight , husband wife -
7 a) 2 people are talking, husband wife – they are happy – he is returning home from work – 1st wife looking and getting jealous , keeping two wives “duniya ka rivaaz” – in future he will stay with 1st wife - loves his 2nd wife thats why 1st is jealous
b) 1st wife will become economically independent – economically stable
8 “Ganesh bhagwan ki pooja” – “patthar kaunsa hai? Bhagwan khush hai. Navratri hai – Parvati jaisi – Dukhi aur majboor hai” - Girl is angry with mother , why is she not coming ?
9 “Husband seva kar raha hai bibi ka” - wife is saying don’t do my seva – wife is happy -
10 Husband / wife sitting happy – “aaraam se soch ki meri bibi kyon nahi aayi ”
11 Bharat ka naksha – to the blank card
7. Name :
Smita Sadanand Panchal – (Epileptic fits)
Age : 33 years
Gender : Female
Education : 10th Pass
SES (Economic Status) : Medium
Marital Status : Unmarried
Occupation: None
Date of Testing : Sunday 12/4/2015
Place where Tested : Thane mental Hospital
Presenting Complaint : Fits
History of Past Illness : For past 15 years she has been admitted in and out of this hospital
Personal History : She has her parents and a married brother and they live together. She claims that she is unmarried due to the seizures and fits she undergoes. She had a fall at age 18 months and damaged her head resulting in the epilepsy. She states that her family loves her very much.
MSE:
Appearance: Neat and hygienic, decent grooming.
Movement and Behaviour: was normal. Positive, bright and happy demeanor. The HTP she did using short strokes with her left hand. Body drawn first then face. When asked to draw a female, she tried twice, flipping pages and then gave up. For house too the strokes were from down to up. She took an inordinate amount of time to draw.
Mood and Affect: Respectful, stable and subdued. She came across as open and honest in her responses.
Eye Contact: Initiated, sustained and maintained.
Speech: Spoke soft and tempo was normal. Length of answers was appropriate. Had clarity in answering questions.
Emotional Status: Checked for hallucinations – answered No to questions whether she heard voices telling him what to do and if she felt that someone was talking about her.
Checked for Delusions – Answered No to questions whether she felt people were after her. Similarly the answers to Dissociation – as she was clear about where she was, who she was, why she was admitted.
Thinking and Perception: Her thought processes were logical and clear. She did not volunteer any irrelevant details nor repeated any words and phrases and her thinking did not appear interrupted.
Memory – Long term and Recent: was intact.
Insight Level: (4) – Because she was oriented in time and space and was aware of her illness and her situation.
Tests Administered: DAP
Behaviour During Testing: The rapport was successfully established and she co operated well.
Purpose of assessment: To assess her personality traits and current level..
Diagnosis and Conclusion: The DAP drawn by Smita, shows a sitting human figure which is Transparant showing breasts and a pronounced belly button. This might go to indicate that she has been sexually abused. Since the torso is joined to the head with a reasonable sized neck, it shows that she is well adjusted with the outside world. Ears of DAP indicate a low tolerance at being corrected or guided. The coconut tree shows an introverted personality. Since the door to the house is open therapy for emotional issues might be received and prove successful.
8. Name :
Swati Samel – (Chronic Motor and Vocal Tic not amounting to Tourette Disorder)
Age : 28 years
Gender : Female
Education : 12th Pass
SES (Economic Status) : Low
Marital Status : Unmarried
Occupation: None
Date of Testing : 23/4/2015
Place where Tested : Thane mental Hospital
Presenting Complaint : Tics
Medical History : This patient falls in the DSM-IV chronic motor and vocal tic disorder not amounting to Tourette disorder, since for the diagnosis of Tourette syndrome, both multiple motor and one or more vocal tics should have been present at some time during the illness, although not necessarily concurrently; the tics should occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year; and during this period there should never be a tic-free period of more than 3 consecutive months; the onset should be before age 18 years.
Personal History : She stays at Dahisar. Has 3 sisters. Father passed away in hospital.
MSE:
Appearance: Unkempt.
Movement and Behaviour: She had facial and vocal tics. She appeared in a depressive state. Would rock her body from side to side at certain times.
Mood and Affect: She periodically gave out a high laugh without any particular cause.
Eye Contact: Not Initiated, sustained and maintained.
Speech: Spoke very little and reluctantly. Had clarity in answering questions.
Emotional Status: Checked for hallucinations – answered No to questions whether she heard voices telling him what to do and if she felt that someone was talking about her.
Checked for Delusions – Answered No to questions whether she felt people were after her. Similarly the answers to Dissociation – as she was clear about where she was, who she was, why she was admitted.
Thinking and Perception: Her thought processes were logical.
Memory – Long term and Recent: was intact.
Insight Level: (3) – Because she was oriented in time and space but seemed fuzzy about her illness and her situation.
Tests Administered: DAP
Behaviour During Testing: The rapport was successfully established and she co operated.
Purpose of assessment: To assess her personality traits and current level..
Diagnosis and Conclusion: The DAP drawn by Swati, shows a sitting female figure which is in reasonable proportion. The torso is joined to the head with a reasonable sized neck, it shows that she is well adjusted with the outside world. The person is centered or just below vertical center on the page, is symmetrical, pleasing to look at, and sufficiently detailed. The same-sex person was drawn first. Since the arms in the picture are the way we reach out to the environment, open arms indicate willingness to engage. Legs and feet are also like the roots of trees, and represent grounding and power too. In the drawing small feet (inadequate base) may indicate a need for security. Since mouth is how we get needs met, cupid bow or luscious lips indicate sexualized needs.
Tree interpretations: The trunk is seen to represent the ego. sense of self, and the intactness of the personality. Thus, large trunks are more ego strength... (think about the saying that a tree that bends lasts through the wind, but one that doesn't snaps, like the ego that is flexible and healthy lasts through the world, but the inflexible and neurotic ego ends up broken). Limbs are the efforts our ego makes to "reach out" to the world and support "things that feed us" what we need. Thus, limbs big branches may be too much reaching out to meet needs. Club shaped branches or very pointy ones represent aggressiveness. Dead branches mean emptiness and hopelessness. Leaves are signs that efforts to reach out are successful, since leaves growing mean the tree is reaching out to the sun and getting food and water. Thus, no leaves could mean feeling barren, while leaves detached from the branches mean the nurturing we get is not very predictable. Roots are what "ground" the tree and people, and typically relate to reality testing and orientation. No roots can mean insecurity and no feeling of being grounded. A ground line sloping downward and away from the drawn whole on either side may reflect a feeling of isolation, exposure, and helplessness in the face of environmental pressures. Squirrels and small animals are an Id intrusion into an area free from ego control.
9. Name :
Avinash Sadashiv Shenai – (Passive – Aggressive and Narcissistic Personality Disorder)
Age : 30 years
Gender : Male
Education : Graduate
SES (Economic Status) : Medium - High
Marital Status: Unmarried
Occupation: Business – making stickers, confectionery, Telecom Electronics Engineer – Wipro cognizant
Date of Testing : 25/4/2015 (Date of Admission : 3/4/2015)
Place where Tested : Thane Mental Hospital
Presenting Complaint : Stress and Aggression
Personal History : Father passed away in 2014. Mother is fashion designer, financially independent, lives in Chembur, who admitted him. Elder Brother married to a psychiatrist living in Pune. He was interested in a girl to marry but was dissuaded by his best friend. Family disputes over property spreading decades. Father and mother used to live in disharmony and there after lived separately. From the manner of his talk and choice of words used to describe his mother, his anger, hostility, although veiled, could be discerned. His hobby was to write about his own life, which he perceived on a grand scale. He seemed to identify with the central character in the novel “Anthem” written by Ayn Rand, stating to have implemented a similar model at the work place in cognizant, which indiciates his underdeveloped sense of self and confirms his grandiosity, entitlement, and superiority.
MSE:
Appearance: Neat and hygienic, decent grooming.
Movement and Behaviour: appeared congenial. He appeared emotionally invested in his personal myth. He appeared in full control of his faculties, cognisant of his choices, and goal-orientated. His behaviour was intentional and directional. He appeared to be a manipulator and hence his chameleon-like ability to change guises, his conduct, and his convictions on a dime.
Mood and Affect: Respectful towards us but disrespectful (using abusive language toward hospital staff behind their back – called him an “ass hole”). He came across as arrogant and confused. There was incongruency in his affect.
Eye Contact: Initiated, sustained and maintained.
Speech: Spoke soft and tempo was normal. Length of answers was long and centred around him.
Emotional Status: Checked for hallucinations – answered No to questions whether he heard voices telling him what to do and if he felt that someone was talking about him. Checked for Delusions – Answered No to questions whether he felt people were after him or that his phone was tapped. Similarly the answers to Dissociation – as he was clear about where he was, who he was, what work he did.
When checking for obsessions, he did mention that he got recurring thoughts about wanting to hurt his mother.
Thinking and Perception: His thought processes were irrational, contradictory and conflicted.
Memory – Long term and Recent: was intact.
Insight Level: (1) – Because he did not know why he was admitted. However he had a good insight into time and space.
Tests Administered: DAP
Behaviour During Testing: The rapport was successfully established and he co operated very well.
Purpose of assessment: To assess his current levels of psychological functioning, more particularly whether he was suicidal or psychotic.
Diagnosis and Conclusion : From the DAP it becomes apparent that his concept of self was all pervasive and dominated the outside world. Although he has drawn a neck, to indicate the connection between self and outside, the disproportionate size of the head would clearly indicate an inflated self concept. The doors and windows in the house drawing are locked indicating a bleak out look and perhaps it might be difficult for intervention to be effective. The coconut tree would indicate an introverted personality.
INTERVENTION
After rapport building Avinash was more than happy to keep talking about his life, his feelings, his exploits in particular. I used the CBT intervention on him at various junctures as more particularly described below:
Avinash elaborated at length about his family disputes over property spreading decades and the disharmony between his parents which made them separate. From the manner of his talk and choice of words used to describe his mother, his anger, hostility, although veiled, could be discerned. He was interested in a girl to marry but was dissuaded by his best friend. He wants to get married but stated that he would leave the choice to his mother. He said it was better to trust her decision than his own. He said that both his parents had strong personalities and he felt that he did not have a voice, or think that he was not being listened to or understood by his family. When I enquired as to why this was so, he said there was less risk factor with a person taking his own decision. (I used the disputation technique of CBT on this issue with Avinash to help him arrive at clarity on his beliefs on this subject). He stated that he had a couple of superficial affairs but had been too busy to make a living to get married.
He mentioned that his life was too stressful and that this city could either help or break a person down – “soul is sucked by the city”, he appeared to be in a victim mode and blaming the city life for his stress. But he also contradicted himself by stating that “its how you fight it out that counts”. His perceived payoffs appeared greater power, control, and negative emotional satisfaction. To this the CBT technique I used was to make him close his eyes and made him go back to the time when he was most relaxed and happy and to visualize the best parts. I let him relive those wonderful memories and then told him to write down in a journal the things in his life he was most thankful for. I explained to him how recording positive thoughts, and even sharing those thoughts online, could help him form new associations in his mind or create new pathways.
When he stated that he had killed and eaten a mongoose when he was in Mangalore, he appeared to be in either a confabulation mode or a narcissistic / self aggrandizement mode wanting attention for this action of his. At this point in terms of an intervention, I effectively articulated, consequences of such an act and allowed him to pause and reflect by himself on the various fall outs of such an act, which made him to get a glimmer of the abnormality of what he had stated to have done.
After spending over 60 minutes with the patient, I wished him well for his recovery and departed.
10. Name : Mozzamil Shaikh - (Substance Abuse)
Age : 12 years
Gender : Male
Education : Schooling
SES (Economic Status) : Low to Medium
Marital Status: Unmarried
Occupation : Student
Date of Testing : Wednesday 8/4/2015
Place where Tested : Sir J. J. Hospital
Presenting Complaint : Substance Abuse
Personal History : No Father. Family disputes over money. Taking whitener for “nasha” – intoxication since past 6 months. Has elder brother for whom he has a high regard.
MSE:
Appearance: Neat. Clean grooming.
Movement and Behaviour: appeared introverted and he had a good vibe about him. He appeared in full control of his faculties, cognisant of his choices. His behaviour was respectful and subdued.
Mood and Affect: Favourable impression of him – honest, straight forward and desiring to come out of his predicament. There appeared to be congruency in his affect.
Eye Contact: Initiated, but not sustained.
Speech: Spoke soft and tempo was normal. Length of answers was short but to the point.
Emotional Status: Checked for hallucinations – answered No to questions whether he heard voices telling him what to do and if he felt that someone was talking about him. Checked for Delusions – Answered No to questions whether he felt people were after him or that his phone was tapped. Similarly the answers to Dissociation – as he was clear about where he was, who he was, what work he did.
Thinking and Perception: His thought processes were aligned and rational.
Memory – Long term and Recent: was intact.
Insight Level: (5) – Because he was aware of his problem and seemed intent on rectifying it. He had a good insight into time and space.
Intervention:
Behaviour During Testing: The rapport was successfully established and he co operated very well.
Diagnosis and Conclusion : Behavioral approaches help in drug abuse treatment, provide incentives for them to remain abstinent, modify their attitudes and behaviors related to drug abuse, and increase their life skills to handle stressful circumstances and environmental cues that may trigger intense craving for drugs and prompt another cycle of compulsive abuse. Keeping this in mind, I started my intervention as under:
Invited the mother to a private session first. Broke ice by asking casual questions. Got her into a comfort zone. Used Socratic method to gather facts. Thereafter, counselled her. Explained the importance of channelizing child to activities of his interest and aptitude. Gave her cell no of Anuj Jain – career counsellor. Guided her in making appropriate choices for her child. Why a boarding school was not the best option for him under those circumstances. The mothers session ended by her enquiring whether she could come back for a second session of counselling with me. After half hour with the mother, I called in Mozzamil. Had occasion to observe him on previous occasion and had formed a favorable impression of him – honest, straight forward and desiring to come out of his predicament. Upon enquiring from him as to what made him take the whitener, he replied saying it cures him of his stomach ache. I explained to him that this would in fact cause damage to his innards and his mind if taken over a long duration. That for stomach ache there were special medicines available with chemists and whitener was not a medicine. Then I enquired about his food habits and his favourite foods. It appeared that since he might be going without food for a while, his stomach aches could be caused by gas and I gently brought it to his notice that even before taking such over the counter medicines, maybe he should rule out gas problems. That he should eat a stomach full whenever he was hungry, so that he does not get gas in his stomach. We had a free wheeling discussion on his favourite school subjects and areas of his interest. I guided him into computer training. At the end of the session when he indicated that he was not inclined to continue with this habit, we did a role play with me offering to him the whitener for free and him steadfastly refusing. I checked with him as to how he would respond if his peers kept pushing him to take the drug. He replied that he would complain to the teacher. I suggested he also consider making new friends. Another behavioural tactic that i shared with him was to make him visualize the most happy parts of each day. Then i asked him to at the end of each day, write down into a diary the things in his life he was most thankful for. I made a practise sheet with him, by giving him time to work this out and then sharing it with me. Recording positive thoughts, and even sharing those thoughts with his brother / mother, could help him form new associations in his mind or create new pathways.
After a half hour talk with Mozzamil, I called his mother back in to give her insight about channelizing him into computer training and that he would instead of wanting to go to boarding school would go to the school his elder brother was going to, so someone could keep an eye out for him.
My aim with the Intervention was to increase motivation to change behaviour and to explore incentives for behaviour change.
1. Name:
D. Singh (Name Changed as this was a high profile case reported in press) (Medico Legal Case @ Sir J. J. Hospital);
The police arrested accused for abetment of suicide. Nearly a week after a family of four was found hanging, the police added rape to the list of charges they are investigating against the accused, who had been arrested earlier on the basis of suicide notes that alleged he had sexually assaulted one of the family members and driven them to suicide.
Age: 32 – 35 years
Gender: Male
Marital Status: Single
Occupation: Business
Date of Testing: 3/3/15
Place where Tested: Sir J. J. Hospital, Psychology Dept.
Presenting Complaint: Brought by the Police for testing
MSE:
Appearance: Neat and hygienic, decent grooming.
Movement and Behaviour: was normal.
Mood and Affect: Respectful, stable and subdued. He came across as open, sincere and honest in his responses. It did not appear that he was hiding any facts when being questioned. There appeared to be congruency in his affect.
Eye Contact: Initiated, sustained and maintained.
Speech: Spoke soft but tempo was normal to fast. Length of answers was appropriate. He had clarity in answering questions posed to him.
Emotional Status: Checked for hallucinations – answered No to questions whether he heard voices telling him what to do and if he felt that someone was talking about him. Checked for Delusions – Answered No to questions whether he felt people were after him or that his phone was tapped. Similarly the answers to Dissociation – as he was clear about where he was, who he was, what work he did.
When checking for obsessions, he did mention that he got recurring thoughts about his lover who had hanged herself in a family suicide pact, although he stated that they had broken off for over 6 months. He stated that he constantly pictured her with her new lovers.
Thinking and Perception: His thought processes were logical, sharp and clear. He did not volunteer any irrelevant details nor repeated any words and phrases and his thinking did not appear interrupted.
Memory – Long term and Recent: was intact.
Insight Level: (5) – Because he asked for help to combat his depression and sleeplessness he was experiencing in jail.
Tests Administered: Rorschach
Behaviour During Testing: The rapport was successfully established and he co operated very well.
Purpose of assessment: To assess his current levels of psychological functioning, more particularly whether he was suicidal or psychotic.
Diagnosis and Conclusion: (Testing of limits was not required as he got over 3 popular responses). From the ROR reading, it appears that this medico legal case is a normal to healthy individual, who is held by the police on charges of abetment to suicide and rape. However the ROR readings do not place him in disturbed category.
2. Name :
Sweta Ambre – (Personality Disorder)
Age: 30 years
Gender: Female
Education: Passed 10th
SES (Economic Status): Low income
Marital Status: Married and separated after 6 months of marriage
Occupation: Unemployed
Date of Testing: Thursday 23rd April, 2015
Place where Tested: Thane Mental Hospital
Presenting Complaint : Severe head aches on the left side of her head. She also has low tolerance to loud sounds.
Personal History: She admitted to having a difficult history growing up at her mother’s home and concurred with the file notings that she beats her mother on occasion.
MSE:
Appearance: Neat and clean
Movement and behaviour : Slow but deliberate
Mood and Affect: Appeared stable although she appeared in pain due to head ache. She appeared honest in answering questions and did not appear to be hiding information.
Eye Contact: Initiated, but not sustained.
Speech: Spoke soft and slowly. Length of answers was short but adequate. There was also adequate clarity in answering questions posed.
Emotional Status: Checked for hallucinations – answered No to questions whether she heard voices telling her what to do and if she felt that someone was talking about her.
Checked for Delusions – Answered No to questions whether she felt people were after her.
Similarly the answers to Dissociation – as she was clear about where she was, who she was.
Thinking and Perception: She did not volunteer any irrelevant details nor repeated any words and phrases and her thinking did not appear interrupted.
Memory – Long term and Recent: was intact.
Insight Level: (2) – Because she is aware that she has problems but blames the husband and her mother.
Tests Administered: TAT and DAP.
Behaviour During Testing: The rapport was successfully established and she co operated although because she was getting tired she kept asking when the process would end.
Purpose of assessment: To assess her personality, current levels of psychological functioning, more particularly to evaluate her patterns of thought, attitudes, and emotional responses to uncover her latent needs and presses.
Diagnosis and Conclusion: From the TAT and DAP is becomes apparent that Sweta, has borderline hostility and aggression, and interpersonal object relations towards her mother showing the extent to which she is emotionally affected by her and which in turn affects her relationships with others; and her ability to understand the complexities of human relationships; her ability to control aggressive impulses; self-esteem issues; and issues of personal identity. The eyes of the DAP indicate emotional bluntness and the out stretched arms and hands indicate a need to seek support and help. The torso is joined to the head without much of a neck which indicates a lack of adjustment by self to the outside world.
3. Name :
Uma Keshav Lingudkar (manic depressive - bi polar)
Age: 35 years
Gender: Female
Education: College drop out
SES (Economic Status): Low
Marital Status: Married. Deserted by husband.
Occupation: Former typist (when in college)
Date of Testing: 4th April, 2015
Place where Tested: Thane Mental Hospital (Admitted since past 4 years by her mother)
Presenting Complaint : No complaints currently – she is not in active phase.
Personal History : She was fond of her father, who would bring her gifts but who expired at age 65. She liked to dress up and was quite chubby, unlike now where she is “kurup zhala”. She has two sisters and one brother and a mother. She has one son age 18 years who is living with her mother presently. Her husband used to beat her on her thighs and her head and she suspected him of having an extra marital affair. She does not know why he left her.
MSE:
Appearance: Unkempt and dirty. Dress torn. Hair dishelved. When she sat on the floor, she was unaware that her legs were apart and she was indecently sitting before us.
Movement and behaviour : Slow and listless. Sometimes muttering and talking to herself.
Mood and Affect: Appeared to be in drug induced state. Her answers were contradictory at times. She was more interested in wanting to lie down and rest rather than be interviewed and tested by us.
Eye Contact: Not initiated, not maintained and not sustained.
Speech: Spoke in a disjointed manner, disconnected at times. She spoke very softly and slowly. Length of answers was short. There was also inadequate clarity in answering questions posed.
Emotional Status: Checked for hallucinations – answered No to questions whether she heard voices telling her what to do and if she felt that someone was talking about her.
Checked for Delusions – Answered No to questions whether she felt people were after her.
Similarly the answers to Dissociation – as she was clear about where she was, who she was.
Thinking and Perception: She did not volunteer any irrelevant details nor repeated any words and phrases and her thinking did not appear interrupted.
Memory – Long term : appeared to be intact. Recent memory was what was giving her trouble.
Sensorium : She was aware that she was at a mental institution and that she had been admitted by her mother. She was aware of time and space. She was unable to do basic addition nor count numbers forward or backward.
Insight Level: (1) – Because she was not aware why she was admitted and had no idea what her problem was
Tests Administered: ROR
Behaviour During Testing: The rapport was established but she got restless very quickly and she repeatedly gave similar to same answers on each ROR card “full pakhru”. She also kept asking when she could leave and when the process would end.
Purpose of assessment: To assess her current levels of psychological functioning.
Diagnosis and Conclusion: From the ROR responses it becomes apparent that Uma, has little touch with reality. Currently she was in a depressive state. She was on medication.
4. Name :
Teresa Fernandes - (Delusions of Grandiosity, Schizophrenic)
Age: 30 years
Gender: Female
Education: 10th Pass – St Joseph High School, Mazagaon
SES (Economic Status): Low - medium
Marital Status: Widow
Occupation: House maid
Date of Testing: 4/4/2015
Place where Tested: Thane mental Hospital
Presenting Complaint: Feeling Lonely
History of Past Illness: Used to hear voices in the past and was afraid that someone would capture her
Personal History: Alcoholic husband used to hit her as well as her father in law. She stays at nalasopara, with her two sons – Hansel and Ryan, before her admission to TMH. Her mother worked as an Aayah in Maasina hospital. She has 3 sisters and one brother who is working in Dubai. She too worked for 8 months in Dubai as a house maid. She mentioned that she liked everything neat and clean and we noticed during interview this trait when she would constantly clean her surroundings and herself.
MSE:
Appearance: Teresa was tidy in her appearance.
Movement and behaviour : She was bright and cheerful when we met her. Some of her movements were jerky and she would smile a lot. Her laughter too was borderline hysterical, but not prolonged.
Mood and Affect: She was happy to sit and talk to us as it alleviated her from her loneliness. She was interested in being interviewed and tested by us.
Eye Contact: Initiated, maintained and sustained.
Speech: Spoke in a disjointed, jerky manner, but it was high spirited. Length of answers was normal. There was also adequate clarity in answering questions posed.
Emotional Status: Checked for hallucinations – answered yes to questions whether she heard voices telling her what to do, but this was in the past, not recent.
Checked for Delusions – Answered yes to questions whether she felt people were after her. During interview stage she mentioned that many people and she herself felt Mother Teresa and herself were the same.
Checked for Dissociation – she was clear about where she was, who she was.
Thinking and Perception: She did not volunteer any irrelevant details nor repeated any words and phrases and her thinking did not appear interrupted.
Memory – Long term : appeared to be intact. Recent memory too was intact.
Sensorium : She was aware that she was at a mental institution and that she had been admitted by her mother. She was aware that it was Easter tomorrow. She was aware of time and space.
Insight Level: (1) – Because she was not aware why she was admitted and had no idea what her problem was
Tests Administered: ROR and DAP
Behaviour During Testing: The rapport was easily and successfully established. Purpose of assessment: To assess her current levels of psychological functioning. Diagnosis and Conclusion: The ROR and DAP responses indicate that Teresa may be suffering from delusion of Grandiosity which is also significantly brought out by the size of the head on the DAP. That she has scant touch with reality is also brought out by the DAP head which has frontal and side face drawn on same head. She was on Medication at the TMH.
5. Name :
Alka Patil (Paranoid Schizophrenia)
Age: 25 years
Gender: Female
Education: Basic Schooling
SES (Economic Status): Low
Marital Status: Separated
Date of Testing: Sat 11/4/2015
Place where Tested: Thane mental Hospital
Presenting Complaint : Alka complained that others were trying to harm her and she felt that she was being constantly watched.
Personal History: She lost her father at an early age and stated that she had been physically brutalized by her elder brother from age of 8 years continuously for three years after which he out station to look for employment. She stated that very often she entertained thoughts about self-harm as well as harming other people.
MSE:
Appearance: Unkempt and dirty. Dress torn. Foul body odour. Hair dishelved.
Movement and behaviour : Most of the time she was quite listless. Sometimes muttering and talking to herself.
Mood and Affect: Had an air of fear about her, looking over her shoulders
Eye Contact: Not initiated, not maintained and not sustained.
Speech: She tended to respond to queries with an unrelated answer, start sentences with one topic and end somewhere completely different, and said illogical things. Her answers were contradictory at times. Spoke in a disjointed manner, disconnected at times. She spoke very softly and slowly.
Emotional Status: Checked for hallucinations – answered Yes to questions whether she heard voices telling her what to do and if she felt that someone was talking about her.
Checked for Delusions – Answered Yes to questions whether she felt people were after her, especially she said that a neighbour was plotting to poison her.
Thinking and Perception: She appeared to have trouble concentrating and maintaining a train of thought.
Sensorium : She was not aware that she was at a mental institution.. She was not aware of time and space. She was unable to do basic addition nor count numbers forward or backward.
Insight Level: (1) – Because she was not aware why she was admitted and had no idea what her problem was.
Tests Administered: ROR
Behaviour During Testing: The rapport was established but she got restless very quickly and she repeatedly gave similar answers on each ROR card “Garbha Pishvi - womb”.
Purpose of assessment: To assess her current levels of psychological functioning.
Diagnosis and Conclusion: From the ROR responses it becomes apparent that Alka has little touch with reality. Currently she was in an anxious state. She was on medication.
Psychotherapy - for patients with paranoid schizophrenia, medications are the key part of treatment; however, psychotherapy is also important. The mainstay for individual psychotherapy is cognitive behavioral therapy, which helps the patient in two ways: identifying negative thoughts, and developing healthy coping strategies. Part of the psychotherapy process is to help the patient understand the symptoms of schizophrenia. Cognitive behavioral therapy can also help the patient cope with the stigma of paranoid schizophrenia.
Social and vocational skills training - this may help the patient live independently; a vital part of recovery for the patient. The therapist can help the patient learn good hygiene, prepare nutritional meals, and have better communication. There may be help in finding work, housing and joining self-help groups.
Compliance (adherence) - compliance or adherence in medicine means following the therapy regime (the treatment plan). Unfortunately, lack of compliance is a major problem for patients with schizophrenia. Patients can go off their medication for long periods during their lives, at enormous personal costs to themselves and often to those around them as well.
As a significant percentage of individuals go off their medication within the first 12 months of treatment, a life-long regimen of both drug and psychological/support therapies are important for treatment to be effective and long-lasting.
ECT (electroconvulsive therapy) - in this procedure an electric current is sent through the brain to produce controlled seizures (convulsion). It may be used on patients with severe symptoms or depression who either have not responded to other treatments or cannot take antidepressants. It is also sometimes used for patients at high risk of suicide. Experts believe that ECT triggers a massive neurochemical release in the brain, caused by the controlled seizure. Side effects may include short-term memory loss (usually resolves rapidly). It is important that the doctor explain clearly the pros and cons of ECT to the patient and/or guardian or family member.
6. Name :
Sarika More Thakur – (Conduct Disorder)
Age: 20 years
Gender: Female
Education : Till 9th
SES (Economic Status): Low
Marital Status : Married
Date of Testing : Sunday 12/4/2015
Place where Tested : Thane mental Hospital
Presenting Complaint : Laughs excessively – disturbs her mother – too much TV watching
Personal History : Resident of Ghatkopar, admitted by mother as patient feels she laughs too much all the time and her mother is disturbed by her behaviour since childhood. Recently she ran away on several occasions from her mother’s home and stayed out overnight. In the past she used to run away from school as the teachers complained to mother about her getting into physical fights with other children and bullying them; she said that when she was not allowed to watch TV, she would get very angry and throw severe temper tantrums; become defiant by not helping with house work. She has 2 children – a son who is studying class V and a daughter. She appears very close to her mother whom she says she misses in hospital. Husband is outstation for work so she has been staying with her mother with her two children.
MSE:
Appearance: Regular – nothing untoward to report.
Movement and behaviour : She appears to be hyper active.
Mood and Affect: Appeared stable but did keep asking when she would be discharged and that she was missing her mother and why was it that her mother had not come to get her home.
Eye Contact: Initiated, but not sustained for too long, nor maintained.
Speech: Spoke fast. Length of answers was adequate. There was also adequate clarity in answering questions posed.
Emotional Status: Checked for hallucinations – answered No to questions whether she heard voices telling her what to do and if she felt that someone was talking about her.
Checked for Delusions – Answered No to questions whether she felt people were after her.
Similarly the answers to Dissociation – as she was clear about where she was, who she was.
Thinking and Perception: She did not volunteer any irrelevant details nor repeated any words and phrases and her thinking did not appear interrupted.
Memory – Long term and Recent: was intact.
Insight Level: (2) – Because she is aware that she has problems but is not able to pin point what.
Tests Administered: TAT and DAP.
Behaviour During Testing: The rapport was successfully established and she co operated well.
Purpose of assessment: To assess her personality, current levels of psychological functioning, more particularly to evaluate her patterns of thought, attitudes, and emotional responses to uncover her latent needs and presses.
Diagnosis and Conclusion: From the TAT and DAP is becomes apparent that Sarika, has borderline hostility and aggression, and interpersonal object relations towards her mother showing the extent to which she is emotionally affected by her and which in turn affects her relationships with others; and her ability to understand the complexities of human relationships; her ability to control aggressive impulses; self-esteem issues; and issues of personal identity. The eyes of the female DAP indicate emotional bluntness whereas the male figure’s pin pointed eyes indicate hyper sensitivity. The out stretched arms and hands indicate a need to seek support and help. The torso is joined to the head without much of a neck which indicates a lack of adjustment by self to the outside world. Bared teeth in both figures would indicate high levels of aggressiveness and / or sexual abuse. Ears of DAP indicate a low tolerance at being corrected or guided.
TAT Testing on Sarika More:
Card No Patients Statements
1 Boy is singing “Bhagwan ka Geet” – He is thinking when will i go to school – In the past when his mother is close, he is happy, he cries when he is away from his mother – His mother and father had spent much money in sickness-
2 India Gate – mother takes child – works – river - father in law helping time to make meal – in future, ghar ka tension – both working and eating-
3 Mother telling daughter not to be truant – not to ask questions – Do her homework – keeps daughter in love – to get well – if in mental hospital mother will get sad -
4 Father in law bending – crying , come quick to save me, im in trouble – Girl wants to stay with mother and not to the cows -
5 She is not able to say – “pehle kya hua hoga”
6 “ladki ke saath ghatna hai” she was happy in the past in the house – this is outside the house – in future everyone will fight , husband wife -
7 a) 2 people are talking, husband wife – they are happy – he is returning home from work – 1st wife looking and getting jealous , keeping two wives “duniya ka rivaaz” – in future he will stay with 1st wife - loves his 2nd wife thats why 1st is jealous
b) 1st wife will become economically independent – economically stable
8 “Ganesh bhagwan ki pooja” – “patthar kaunsa hai? Bhagwan khush hai. Navratri hai – Parvati jaisi – Dukhi aur majboor hai” - Girl is angry with mother , why is she not coming ?
9 “Husband seva kar raha hai bibi ka” - wife is saying don’t do my seva – wife is happy -
10 Husband / wife sitting happy – “aaraam se soch ki meri bibi kyon nahi aayi ”
11 Bharat ka naksha – to the blank card
7. Name :
Smita Sadanand Panchal – (Epileptic fits)
Age : 33 years
Gender : Female
Education : 10th Pass
SES (Economic Status) : Medium
Marital Status : Unmarried
Occupation: None
Date of Testing : Sunday 12/4/2015
Place where Tested : Thane mental Hospital
Presenting Complaint : Fits
History of Past Illness : For past 15 years she has been admitted in and out of this hospital
Personal History : She has her parents and a married brother and they live together. She claims that she is unmarried due to the seizures and fits she undergoes. She had a fall at age 18 months and damaged her head resulting in the epilepsy. She states that her family loves her very much.
MSE:
Appearance: Neat and hygienic, decent grooming.
Movement and Behaviour: was normal. Positive, bright and happy demeanor. The HTP she did using short strokes with her left hand. Body drawn first then face. When asked to draw a female, she tried twice, flipping pages and then gave up. For house too the strokes were from down to up. She took an inordinate amount of time to draw.
Mood and Affect: Respectful, stable and subdued. She came across as open and honest in her responses.
Eye Contact: Initiated, sustained and maintained.
Speech: Spoke soft and tempo was normal. Length of answers was appropriate. Had clarity in answering questions.
Emotional Status: Checked for hallucinations – answered No to questions whether she heard voices telling him what to do and if she felt that someone was talking about her.
Checked for Delusions – Answered No to questions whether she felt people were after her. Similarly the answers to Dissociation – as she was clear about where she was, who she was, why she was admitted.
Thinking and Perception: Her thought processes were logical and clear. She did not volunteer any irrelevant details nor repeated any words and phrases and her thinking did not appear interrupted.
Memory – Long term and Recent: was intact.
Insight Level: (4) – Because she was oriented in time and space and was aware of her illness and her situation.
Tests Administered: DAP
Behaviour During Testing: The rapport was successfully established and she co operated well.
Purpose of assessment: To assess her personality traits and current level..
Diagnosis and Conclusion: The DAP drawn by Smita, shows a sitting human figure which is Transparant showing breasts and a pronounced belly button. This might go to indicate that she has been sexually abused. Since the torso is joined to the head with a reasonable sized neck, it shows that she is well adjusted with the outside world. Ears of DAP indicate a low tolerance at being corrected or guided. The coconut tree shows an introverted personality. Since the door to the house is open therapy for emotional issues might be received and prove successful.
8. Name :
Swati Samel – (Chronic Motor and Vocal Tic not amounting to Tourette Disorder)
Age : 28 years
Gender : Female
Education : 12th Pass
SES (Economic Status) : Low
Marital Status : Unmarried
Occupation: None
Date of Testing : 23/4/2015
Place where Tested : Thane mental Hospital
Presenting Complaint : Tics
Medical History : This patient falls in the DSM-IV chronic motor and vocal tic disorder not amounting to Tourette disorder, since for the diagnosis of Tourette syndrome, both multiple motor and one or more vocal tics should have been present at some time during the illness, although not necessarily concurrently; the tics should occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year; and during this period there should never be a tic-free period of more than 3 consecutive months; the onset should be before age 18 years.
Personal History : She stays at Dahisar. Has 3 sisters. Father passed away in hospital.
MSE:
Appearance: Unkempt.
Movement and Behaviour: She had facial and vocal tics. She appeared in a depressive state. Would rock her body from side to side at certain times.
Mood and Affect: She periodically gave out a high laugh without any particular cause.
Eye Contact: Not Initiated, sustained and maintained.
Speech: Spoke very little and reluctantly. Had clarity in answering questions.
Emotional Status: Checked for hallucinations – answered No to questions whether she heard voices telling him what to do and if she felt that someone was talking about her.
Checked for Delusions – Answered No to questions whether she felt people were after her. Similarly the answers to Dissociation – as she was clear about where she was, who she was, why she was admitted.
Thinking and Perception: Her thought processes were logical.
Memory – Long term and Recent: was intact.
Insight Level: (3) – Because she was oriented in time and space but seemed fuzzy about her illness and her situation.
Tests Administered: DAP
Behaviour During Testing: The rapport was successfully established and she co operated.
Purpose of assessment: To assess her personality traits and current level..
Diagnosis and Conclusion: The DAP drawn by Swati, shows a sitting female figure which is in reasonable proportion. The torso is joined to the head with a reasonable sized neck, it shows that she is well adjusted with the outside world. The person is centered or just below vertical center on the page, is symmetrical, pleasing to look at, and sufficiently detailed. The same-sex person was drawn first. Since the arms in the picture are the way we reach out to the environment, open arms indicate willingness to engage. Legs and feet are also like the roots of trees, and represent grounding and power too. In the drawing small feet (inadequate base) may indicate a need for security. Since mouth is how we get needs met, cupid bow or luscious lips indicate sexualized needs.
Tree interpretations: The trunk is seen to represent the ego. sense of self, and the intactness of the personality. Thus, large trunks are more ego strength... (think about the saying that a tree that bends lasts through the wind, but one that doesn't snaps, like the ego that is flexible and healthy lasts through the world, but the inflexible and neurotic ego ends up broken). Limbs are the efforts our ego makes to "reach out" to the world and support "things that feed us" what we need. Thus, limbs big branches may be too much reaching out to meet needs. Club shaped branches or very pointy ones represent aggressiveness. Dead branches mean emptiness and hopelessness. Leaves are signs that efforts to reach out are successful, since leaves growing mean the tree is reaching out to the sun and getting food and water. Thus, no leaves could mean feeling barren, while leaves detached from the branches mean the nurturing we get is not very predictable. Roots are what "ground" the tree and people, and typically relate to reality testing and orientation. No roots can mean insecurity and no feeling of being grounded. A ground line sloping downward and away from the drawn whole on either side may reflect a feeling of isolation, exposure, and helplessness in the face of environmental pressures. Squirrels and small animals are an Id intrusion into an area free from ego control.
9. Name :
Avinash Sadashiv Shenai – (Passive – Aggressive and Narcissistic Personality Disorder)
Age : 30 years
Gender : Male
Education : Graduate
SES (Economic Status) : Medium - High
Marital Status: Unmarried
Occupation: Business – making stickers, confectionery, Telecom Electronics Engineer – Wipro cognizant
Date of Testing : 25/4/2015 (Date of Admission : 3/4/2015)
Place where Tested : Thane Mental Hospital
Presenting Complaint : Stress and Aggression
Personal History : Father passed away in 2014. Mother is fashion designer, financially independent, lives in Chembur, who admitted him. Elder Brother married to a psychiatrist living in Pune. He was interested in a girl to marry but was dissuaded by his best friend. Family disputes over property spreading decades. Father and mother used to live in disharmony and there after lived separately. From the manner of his talk and choice of words used to describe his mother, his anger, hostility, although veiled, could be discerned. His hobby was to write about his own life, which he perceived on a grand scale. He seemed to identify with the central character in the novel “Anthem” written by Ayn Rand, stating to have implemented a similar model at the work place in cognizant, which indiciates his underdeveloped sense of self and confirms his grandiosity, entitlement, and superiority.
MSE:
Appearance: Neat and hygienic, decent grooming.
Movement and Behaviour: appeared congenial. He appeared emotionally invested in his personal myth. He appeared in full control of his faculties, cognisant of his choices, and goal-orientated. His behaviour was intentional and directional. He appeared to be a manipulator and hence his chameleon-like ability to change guises, his conduct, and his convictions on a dime.
Mood and Affect: Respectful towards us but disrespectful (using abusive language toward hospital staff behind their back – called him an “ass hole”). He came across as arrogant and confused. There was incongruency in his affect.
Eye Contact: Initiated, sustained and maintained.
Speech: Spoke soft and tempo was normal. Length of answers was long and centred around him.
Emotional Status: Checked for hallucinations – answered No to questions whether he heard voices telling him what to do and if he felt that someone was talking about him. Checked for Delusions – Answered No to questions whether he felt people were after him or that his phone was tapped. Similarly the answers to Dissociation – as he was clear about where he was, who he was, what work he did.
When checking for obsessions, he did mention that he got recurring thoughts about wanting to hurt his mother.
Thinking and Perception: His thought processes were irrational, contradictory and conflicted.
Memory – Long term and Recent: was intact.
Insight Level: (1) – Because he did not know why he was admitted. However he had a good insight into time and space.
Tests Administered: DAP
Behaviour During Testing: The rapport was successfully established and he co operated very well.
Purpose of assessment: To assess his current levels of psychological functioning, more particularly whether he was suicidal or psychotic.
Diagnosis and Conclusion : From the DAP it becomes apparent that his concept of self was all pervasive and dominated the outside world. Although he has drawn a neck, to indicate the connection between self and outside, the disproportionate size of the head would clearly indicate an inflated self concept. The doors and windows in the house drawing are locked indicating a bleak out look and perhaps it might be difficult for intervention to be effective. The coconut tree would indicate an introverted personality.
INTERVENTION
After rapport building Avinash was more than happy to keep talking about his life, his feelings, his exploits in particular. I used the CBT intervention on him at various junctures as more particularly described below:
Avinash elaborated at length about his family disputes over property spreading decades and the disharmony between his parents which made them separate. From the manner of his talk and choice of words used to describe his mother, his anger, hostility, although veiled, could be discerned. He was interested in a girl to marry but was dissuaded by his best friend. He wants to get married but stated that he would leave the choice to his mother. He said it was better to trust her decision than his own. He said that both his parents had strong personalities and he felt that he did not have a voice, or think that he was not being listened to or understood by his family. When I enquired as to why this was so, he said there was less risk factor with a person taking his own decision. (I used the disputation technique of CBT on this issue with Avinash to help him arrive at clarity on his beliefs on this subject). He stated that he had a couple of superficial affairs but had been too busy to make a living to get married.
He mentioned that his life was too stressful and that this city could either help or break a person down – “soul is sucked by the city”, he appeared to be in a victim mode and blaming the city life for his stress. But he also contradicted himself by stating that “its how you fight it out that counts”. His perceived payoffs appeared greater power, control, and negative emotional satisfaction. To this the CBT technique I used was to make him close his eyes and made him go back to the time when he was most relaxed and happy and to visualize the best parts. I let him relive those wonderful memories and then told him to write down in a journal the things in his life he was most thankful for. I explained to him how recording positive thoughts, and even sharing those thoughts online, could help him form new associations in his mind or create new pathways.
When he stated that he had killed and eaten a mongoose when he was in Mangalore, he appeared to be in either a confabulation mode or a narcissistic / self aggrandizement mode wanting attention for this action of his. At this point in terms of an intervention, I effectively articulated, consequences of such an act and allowed him to pause and reflect by himself on the various fall outs of such an act, which made him to get a glimmer of the abnormality of what he had stated to have done.
After spending over 60 minutes with the patient, I wished him well for his recovery and departed.
10. Name : Mozzamil Shaikh - (Substance Abuse)
Age : 12 years
Gender : Male
Education : Schooling
SES (Economic Status) : Low to Medium
Marital Status: Unmarried
Occupation : Student
Date of Testing : Wednesday 8/4/2015
Place where Tested : Sir J. J. Hospital
Presenting Complaint : Substance Abuse
Personal History : No Father. Family disputes over money. Taking whitener for “nasha” – intoxication since past 6 months. Has elder brother for whom he has a high regard.
MSE:
Appearance: Neat. Clean grooming.
Movement and Behaviour: appeared introverted and he had a good vibe about him. He appeared in full control of his faculties, cognisant of his choices. His behaviour was respectful and subdued.
Mood and Affect: Favourable impression of him – honest, straight forward and desiring to come out of his predicament. There appeared to be congruency in his affect.
Eye Contact: Initiated, but not sustained.
Speech: Spoke soft and tempo was normal. Length of answers was short but to the point.
Emotional Status: Checked for hallucinations – answered No to questions whether he heard voices telling him what to do and if he felt that someone was talking about him. Checked for Delusions – Answered No to questions whether he felt people were after him or that his phone was tapped. Similarly the answers to Dissociation – as he was clear about where he was, who he was, what work he did.
Thinking and Perception: His thought processes were aligned and rational.
Memory – Long term and Recent: was intact.
Insight Level: (5) – Because he was aware of his problem and seemed intent on rectifying it. He had a good insight into time and space.
Intervention:
Behaviour During Testing: The rapport was successfully established and he co operated very well.
Diagnosis and Conclusion : Behavioral approaches help in drug abuse treatment, provide incentives for them to remain abstinent, modify their attitudes and behaviors related to drug abuse, and increase their life skills to handle stressful circumstances and environmental cues that may trigger intense craving for drugs and prompt another cycle of compulsive abuse. Keeping this in mind, I started my intervention as under:
Invited the mother to a private session first. Broke ice by asking casual questions. Got her into a comfort zone. Used Socratic method to gather facts. Thereafter, counselled her. Explained the importance of channelizing child to activities of his interest and aptitude. Gave her cell no of Anuj Jain – career counsellor. Guided her in making appropriate choices for her child. Why a boarding school was not the best option for him under those circumstances. The mothers session ended by her enquiring whether she could come back for a second session of counselling with me. After half hour with the mother, I called in Mozzamil. Had occasion to observe him on previous occasion and had formed a favorable impression of him – honest, straight forward and desiring to come out of his predicament. Upon enquiring from him as to what made him take the whitener, he replied saying it cures him of his stomach ache. I explained to him that this would in fact cause damage to his innards and his mind if taken over a long duration. That for stomach ache there were special medicines available with chemists and whitener was not a medicine. Then I enquired about his food habits and his favourite foods. It appeared that since he might be going without food for a while, his stomach aches could be caused by gas and I gently brought it to his notice that even before taking such over the counter medicines, maybe he should rule out gas problems. That he should eat a stomach full whenever he was hungry, so that he does not get gas in his stomach. We had a free wheeling discussion on his favourite school subjects and areas of his interest. I guided him into computer training. At the end of the session when he indicated that he was not inclined to continue with this habit, we did a role play with me offering to him the whitener for free and him steadfastly refusing. I checked with him as to how he would respond if his peers kept pushing him to take the drug. He replied that he would complain to the teacher. I suggested he also consider making new friends. Another behavioural tactic that i shared with him was to make him visualize the most happy parts of each day. Then i asked him to at the end of each day, write down into a diary the things in his life he was most thankful for. I made a practise sheet with him, by giving him time to work this out and then sharing it with me. Recording positive thoughts, and even sharing those thoughts with his brother / mother, could help him form new associations in his mind or create new pathways.
After a half hour talk with Mozzamil, I called his mother back in to give her insight about channelizing him into computer training and that he would instead of wanting to go to boarding school would go to the school his elder brother was going to, so someone could keep an eye out for him.
My aim with the Intervention was to increase motivation to change behaviour and to explore incentives for behaviour change.