CASE PRESENTATION

Presenter: Dr. Nilesh BasarkarModerator: Dr. C. Pinto, Dr. J. P. Rawat

Dept. Of PsychiatryJRH BCT.

History• A 19 yrs old Right handed Hindi speaking Unmarried, Hindu male Student of 12th std Resident of Dahisar• Complaints- Self- Headache Sadness of mood

• Objective data- Mother (Adequate & reliable)• H/o – Socially withdrawn behavior Lethargy Loss of interest in surrounding• Total Duration- 6 months.

ODP• Patient was apparently alright 1 yr back.• When he started symptoms without stressor in the form

of Overfriendliness Excess talk Decreased sleep Hyper religious behavior• These symptoms mild in nature & lasted for 6 months.

But they went unnoticed & he was doing well in socio- occupational areas.

• But since last 6 months as the symptoms changed following failure in 12th in the form of

Lethargy Lack of interest in surrounding Socially with drawn behavior• Family members worried & got him to hospital

for psychiatric consultation.

Negative history

• No h/o hearing of voices, muttering to self, laughing alone.

• No h/o suspiciousness, bizarre behavior.• No h/o Repeated hand washing, checking or

cleaning behavior.• No h/o seizure or neurological disorder.• No h/o any substance abuse.

Past & Family history

• No similar complaints in past were noted.• No family h/o Mental illness, Substance abuse,

MR, or Suicide.

Personal History

• Birth history- Full tem normal home delivery• Milestones- Normal• Education- Average in studies Educated up to 11th Failed in 12th • Pre morbid personality- Minimal friends -Poor social involvement -Hobby- watching TV

Physical Examination

• GENERAL EXAMINATION-• Conscious, cooperative & well oriented• General condition fair• Pulse- 72 /min• BP- 130/70 mmHg• RR- 18/min

• NEUROLOGICAL EXAMINATION- Higher functions Sensory system Motor system All examination findings within normal limit.• SYSTEMIC EXAMINATION- CVS, RS, PA findings within normal limits.

Mental Status Examination• General Appearance- Conscious , Cooperative , Kept quite most of the

time during interview. Well dressed• Eye to Eye Contact- Initiated & Maintained• Rapport- Established & Maintained• Attention – Arousable & sustained

• Mood- Sad• Affect- Appropriate• Speech- Continous , Coherent, Relevant Decreased in amount• Thoughts – Ideas of helplessness, hopelessness & worthlessness present. Denies delusions Concept- Simple- Intact

Abstract- Intact

• Perception- No perceptual abnormility present.• Memory- Registration- 3/3 Recall-3/3• Intelligence- General Fund Of Information & Calculation- Both average.• Judgment- Social-Intact Test-Intact• Insight- 3/6 (claims illness as physical disease)

DIFFRENTIAL DIAGNOSIS

• Depressive phase in case of Bipolar Disorder.• Schizoaffective Disorder.

INVESTIGATIONS

• Routine Blood & Urine Examination- Normal• X-Ray Chest-Normal• ECG-Normal• Fundus Exam- Normal• EEG- Normal• MRI Brain- Normal

• PSYCHOMETRIC ASSESSMENT-• BPRS- 24 (mild to moderate psychopathology) • HDRS- 19 (significant depression) • YMRS- 3 (No significant manic symptoms)

DIAGNOSIS

• DSM IV TR- Axis I- Depression in case of Bipolar Mood D/o Axis II- Cluster A personality traits Axis III- No diagnosis Axis IV- Failure in 12th examination Axis V- GAF 61-70 at present & 71-80 before 1

year.

TREATMENT

• Patient was treated on OPD basis.• PHARMACOTHERAPY- Tab. Escitalopram 10 mg (1-0-0) Tab. Na- Valproate 250 mg (1-0-1) Tab. Lorazepam 2 mg (0-0-1)

• PSYCHOTHERAPY-• Individual Psychotherapy- Patient was

explained about nature of illness & importance of compliance.

• Family psycho education- Family members were explained attitude

towards patient & way of dealing with him. • Supportive psychotherapy was also given.

COURSE & TREATMENT RESPONSE

• Patient had depressive features since last 6 months.

• Previous history shows features of hypomania which went unnoticed.

• He was never treated• After starting medication patient improved

40% in 2 weeks.

• He showed 70% improvement after 1 month. • Patient is on regular follow up for medication.

Depression: A global crisis