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1. Case Presentation Dr. Pratik Bachhar 3 rd year resident Department of Psychiatry, NMCTH Birgunj

2. Patient particulars Name: Mrs. K. Gupta Age: 24 years Sex: female Religion: Hindu Education: Graduate degree Occupation: Homemaker Marital status: Married Socioeconomic Status: Lower middle class Family type: Joint Address: Raxaul

3. Source of referral: Family members Source of information: Patient herself Father: Mr. M.K. Gupta, 55 year, married, primary education, shopkeeper, has stayed with the patient during later period of illness Brother: Mr. B. Gupta, 30 years, married, Graduate degree, shopkeeper, has stayed with the patient during later period of illness Aunt: Mrs. P. Gupta, 27 years, married, higher secondary education, homemaker, has stayed with the patient during later period of illness Information provided is reliable and adequate

4. Total duration of illness: 4 days Onset is abrupt Course is continuous Predisposing factors: not elicited Precipitating factors: Stressful life event Perpetuating factors: not elicited

5. Chief complaints According to the patient: Kuch nahi hua hai mujhe According to informant: Disturbed sleep for 4 days Suspiciousness that her in-laws are trying to kill her for 3 days

6. History of presenting illness: According to the informant the patient was married on 11 th July 2024 i.e. 13 days prior to presentation. 4 days prior to presentation the patient’s husband left for work to a different city and all of the patients’ family members were present to bid him farewell. The patient appeared to be in her usual state of health so her family members returned and left her with her in-laws. She had her meal and helped in housework that day. The patients aunt received a call later that midnight and was informed that the patient was behaving abnormally and to come at once. On further asking what had happened, she was told that the patient only screamed so her mother-in-law and sister in laws tried to make her quiet but as the patient kept on making noise they covered her mouth to dampen the sounds.

7. Soon all the family members arrived and saw that the patient refused to speak and reason with them and tried to run away so they tied her up using ropes. According to the in laws they thought that the patient had become possessed and called for a faith healer right away. When the faith healer arrived, she commanded the family members, who allegedly beat the patient with broom to ward off evil and the faith healer also performed some rituals before leaving. The patient did not sleep at all that night and remained bound by ropes. She did not speak to any one but constantly stared at them not to let anyone out of her sight. When she was offered the phone to talk to her mother the patient did not speak and refused to communicate at all.

8. Next day the patients family members arrived and on seeing the patient she appeared to be scared sitting on the floor. On asking what had happened, told that at midnight she was sleeping with her mother and sister in law when she felt someone touching her inappropriately. She woke up at once and looked around but did not see anyone. She started to shout and scream for help that woke up her mother and sister in laws and they tried to make her quiet by covering her mouth. She also told them that there was a female faith healer who had beat her, cast a spell on her and made her drink an enchanted portion. She did all that because her in laws had told her to as they wanted to drive her mad and separate her from her husband. She also appeared scared of them and did not go anywhere near them. She said, “I want to tell you what all they did to me but I am not able to do so. The faith healers spell do not let me to speak freely. Please take me back home with you or they will kill me for sure.”

9. Both the families started arguing so the patients aunt took her away from them and told the patient to have a bath and guided her to the bathroom. After a while when the aunt checked, the bathroom door was open and patient was sitting on the floor and had not even started to bathe. When asked what had happened the patient looked around first before speaking and appeared to be careful in her manner of speaking. She whispered that her in laws had fit cameras in the bathroom and were watching and hearing everything. The informant checked around but found nothing so she proceeded to help the patient with a bath. Afterwards both the families brought another faith healer but no improvement was seen and patient only became more fearful and continued to request her family members to take her home as she was afraid her in laws would surely kill her.

10. On the way home she remained silent for most of the journey. After some time she told her aunt to call the police saying, “I want to tell them something.” On asking what it was the patient said, “I will write it down for the police as I cannot say it I am scared.” On asking why she couldn’t speak about it she said, “My in-laws had fit a chip in my phone and they were listening to everything that was being said.” She even asked everyone to switch off their phones as even their phones were being monitored. On asking how she knew of it the patient did not answer further and asked everyone to keep quiet. As the family members did not comply the patient started saying, “even you all have been influenced by my in laws. Did you drink or eat anything over there?” After being reassured that no one had eaten anything the patient calmed down for a bit.

11. They reached home at midnight. All the family members had food together and the patient appeared to be calmer than before but she spoke very less. The patient, her aunt and mother proceeded to sleep in the same room at night. They noticed that the patient did not sleep at all that night and her eyes remained open and when asked why she wasn’t sleeping the patient replied, “will my husband accept me as I am,” and fell silent again and did not answer any further questions. At night the informants also noticed that the patient was moving her lips as if speaking to someone but when asked the patient did not respond at all and ignored their questions.

12. The next day the patient stayed by herself and did not speak to anyone unless approached. She had her meals well. At times when she was muttering by herself her aunt asked what she was saying. The patient replied, “my husband has said that everything is alright. Don’t worry everything is safe.” On asking further had the patient talked to him over the phone and what else they spoke about, the patient did not reply and kept staring away. The patient remained awake for most of the night but slept for 1 to 2 hours when nearing dawn.

13. She lay awake on her bed when she was approached by her aunt who asked her to freshen up. The patient appeared to be staring at her continuously her. On asking what had happened, the patient moved her eyes from side to side as if to observe the people around her but did not speak. It lasted for about one minute and she appeared to relax for about 5 minutes and she had another similar episode lasting one minute. There was no abnormal jerky body movements, no uprolling of eyes, no tongue bite no frothing from mouth, no drooling of saliva no jerky body movements no bowel and bladder incontinence seeing all this she was rushed to a vehicle in five minutes when she asked where they were going she was then brought to NMCTH emergency for further evaluation.

14. Negative history No h/o headache, fever, vomiting, head trauma No h/o use of any psychoactive substances No h/o depressed mood, decreased energy leading to easy fatiguability, loss of interest in previously pleasurable activities No h/o overfamiliarity, talkativeness, distractibility, hyper religious behavior No h/o chest pain, difficulty in breathing, palpitations, feeling of impending doom No h/o distressing thoughts or repetitive actions

15. Past history No h/o hypertension, diabetes mellitus, pulmonary tuberculosis or thyroid disorder No h/o any surgical illness or procedures No h/o any other psychiatric disorders

16. Family genogram-maternal Family

17. Husband’s family

18. Family history 19 members in the maternal family, 7 members in husbands family Maternal family: Joint family, husband’s family: nuclear family Patient is the youngest among 3 siblings Head of family and source of income: father/father-in-law Primary caregiver is the patients mother/ mother-in-law Interpersonal relations: Maternal family: Patient is respectful towards family members and listens to their advice There is no h/o continuous stressors or discord in the family Family members understand the nature of illness and are supportive emotionally and financially

19. Present living conditions: Husband’s family: IPR not well established with in-laws as the patient was married 13 days prior to presentation Husband left home to go to Delhi a week after marriage due to work and he stays there. She slept with her mother-in-law and sister-in-law after her husband left for work. No family members visited the patient during ward stay but acc. to the patient’s brother, they asked about the patient via phone. Interview could not be conducted as the family members did not agree to share any contact details and did not consent to examiner communicating with the patient’s in-laws No h/o any medical or psychiatric disorders in family

20. Kutcha house made of bricks and mud One floor, about Total 4 rooms with adequate lighting but not with adequate cross ventilation as 2 rooms, including the patients room does not have a window. One kitchen and 3 bedrooms Patient and wife with 2 sons sleep in one room Patients older brother, his wife and one child in one room Patients mother and father sleep in one room Toilet outside the house at about 10 metres distance Bath in the angan between the house and toilet Water source: handpump in the patients house Sewage is dumped through dug out canal system in the main sewers of the neighbourhood .

21. Personal history Ante-natal History Planned and wanted pregnancy Age of parents at conception: Mother 28 years; Father: 31 years , Conception by natural methods No h/o Medical illness (Diabetes/ HTN Jaundice /STD) No h/o hyper-emesis, 1 st trimester X-ray exposure, drug intake (other than folate, iron, calcium) or psychotropic, alcohol or tobacco use Regular ante-natal visits and immunized with 2 doses of TT USG was done and no abnormality found No h/o complications such as Rh incompatibility, twin pregnancy, threatened abortion , Bleeding, Pre-eclampsia, Eclampsia Fetal movements were perceived throughout the pregnancy (not excessive or sluggish)

22. Natal history Born at the hospital via NVD at term. Presentation: longitudinal, cephalic No h/o large head, low placenta, prolapsed cord, cord around neck, fetal distress, prolonged labor, PROM, non-progress of labor, or meconium stained liquor, excessive bleeding

23. Neonatal and post-natal History Birth weight could not be remembered , cried immediately after birth, color : Pink No h/o Respiratory distress Activity Normal, Suckling Normal Feeding : Breast fed exclusively for initial 6 months : on demand No feeding problem No abnormalities in Urine/ stools No congenital anomalies/ stigmata noticed No h/o Neonatal seizures, Jaundice, Infection, Hospital stay Immunized according to Immunization program of India, documents not available

24. Developmental milestones: Neck holding 4 months Sitting without support 8 months Standing with support 12 Walking 14 months Fluent speech/Sentence 4 years Bowel Control 3 years Bladder Control 3 years

25. Childhood and adolescent history Neurotic traits Obstinacy : none No h/o temper tantrums No h/o nail biting, thumb sucking, morbid fear of persons/ animals/ darkness No h/o enuresis/encopresis

26. Play Preferred group play with her siblings and cousins, she mixed well with other children from her class No indifference towards playmates or siblings No h/o inappropriate intrusion or impulsivity during play Understood games governed by rules Showed co-operation during play Did not bully other children Did no get bullied by other children

27. Education Type of schooling: day-boarding School Nature of school: Normal Any literacy exposure before formal schooling? No. Started schooling at approximately 5 years Class 1-8: in her village, changed as school was limited till class 8 Class 9-10: in Raxaul , changed as school was limited till class 10 Class 11-12: Raja Ram School in Raxaul Graduate degree in B.Sc : Khemchand Tarachand Mahavidyalaya, Raxaul

28. Attendance: Regular Scholastic performance: Average, aggregates could not be remembered but according to the informants patient always fell in the top 5 ranks Peer group adjustment: average Problems with teachers: Nil Class room behavior: Favorable, no altercations with peers or teachers Frequency and reasons for change of school Change of school due to schools limitations

29. Occupational history: Has not worked outside home, but she has always wanted to help in household income which was supported by both her families. Homemaker Menstrual history: Menarche : 13 years Regular cycles, 30 +/- 3 days Flow: 4-5 days, uses 3-4 pads/day No h/o dysmenorrhea, menorrhagia L.M.P.: 5 July, 2024

30. Relationship and sexual history: Identifies as a female, attracted to males Start of sexual interest could not be elicited According to the patient’s aunt she used to talk to a boy from college before marriage via messages. Family members had found out but no discords occurred due to it. Family members denied any knowledge regarding details of the incident. Had not engaged in sexual activity before marriage She has not engaged in masturbation. No specific fantasies were elicited.

31. Marital history: MF: 13 days Arranged marriage Consent from all concerned parties. Discord related to dowry occurred over a period of 1 year prior to marriage. Issues were resolved prior to marriage but acc. to her brother the in-laws even after marriage pressurized the patient asking her for more things and money. After marriage husband had found out that the patient used to talk to a boy via messages and patient had discussed about it with her aunt. Marriage had been consummated before the patient’s husband left for work. Details regarding sexual relations could not be elicited as no family members including husband were available for interview. Substance history: No h/o use of any psychoactive substances

32. Premorbid personality During school she got along well with her classmates. She also got along well with her siblings. She was not uncomfortable meeting new people and did not take time to adjust to them. She was respectful towards family members, elders and friends She was a hard working person and completed all her homework by herself. She dedicated time towards studying after school and she also helped with household work Interpersonal relation with family members and friends was harmonious.

33. She was not overtly religious but respected her family sentiments towards religion she also conducted arati everyday at home and also versed religious texts. General mood was euthymic and energy was average. During stress she handled her problem by herself mostly but also asked for help from siblings and parents. She enjoyed studying and wanted to work even after marriage which was supported by her parents and husband. She enjoyed listening to music and liked singing in her free time. Sleep, meal, bowel and bladder habits were regular. Not actively engaged in intellectual activities. Impression : Well adjusted

34. Case conceptualization

35. GENERAL EXAMINATION Date of admission: 24 July , 2024 Date of examination : 24 July , 2024 Weight: 60 Kgs Height: 5feet, 4 inches (160cms) BMI: 23.4 kg/m2 Vitals: Temperature: 98F Pulse: 78/min Respiration rate: 16 breaths/min SPO 2 : 98 % BP: 120/80 mm/Hg Pallor/Icterus / Lymphadenopathy/Cyanosis / Clubbing/Dehydration: Not seen SYSTEMIC EXAMINATION: Cardiovascular: S1S2M0 Respiratory: B/L Vesicular breath sounds, no added sounds Gastro-intestinal: Soft, non tender, no organs palpable, Bowel sounds 3/min

36. Kirby’s examination method General reaction and posture Spontaneous acts Patient frequently moved around the ward, peeking from the door and asking for family members. She appeared to be keeping an eye on family members. No assaultive acts observed towards family members, ward staff or the interviewer Hygiene was maintained but grooming was minimally unkempt as her hair was untidy. She was eating voluntarily and dressing by herself. Her actions did not appear to be too slow or too fast.

37. Behavior towards examiner: She was uncooperative during the interview. She did not respond verbally to any questions asked but sometimes looked up and made eye contact with the interviewer. Voluntary postures: She appeared to maintain a comfortable posture throughout the period of observation. She did not let the interviewer or family members put her in an uncomfortable posture and resisted by withdrawing her arms when tried. Her behavior remained constant throughout the period of observation in the ward. Impression: increased PMA, no posturing

38. Facial movements and expression She appeared to be alert to what was being said to and around her but did not respond to the interviewer when approached. At times she also appeared to be smiling and talking when she was with her family members. Impression: reactive facial movements and expression Eyes and pupils Eyes remained open during the interview. Patient appeared to be listening to the questions but did not respond. She did not comply when asked to track moving pen She evaded making eye contact with the interviewer but made EC with family members while communicating Blinking rate appeared to be within normal range, no flickering or other abnormal movements noted in eyelids. Patient closed her eyes and moved backwards to avoid when hand was moved suddenly towards her face. She closed her eyes when light was shone. Impression: pupils 3-4mm, round, regular, b/l symmetrical, vision grossly intact

39. Reaction to examiners tests and questions: She did not follow command when asked to protrude tongue and to show teeth She remained unco-operative throughout the interview No automatic obedience, echolalia or echopraxia noted. Movements of limbs appeared to be within normal range, not too slow, fast or interrupted. Muscular reactions: Tone of muscles not increased or decreased No urinary or fecal incontinence

40. Emotional responsiveness: She had regular conversations with family members but mostly about her persecutory delusion. She looked towards examiner when hands were clapped behind her unexpectedly. Impression: Reactive Speech: No spontaneous speech with interviewer but spoke in a regular manner with family members. Impression: No mutism Offered the patient paper and pen to write: Refused

41. Diagnostic formulation Mrs. K. Gupta, 24 years, married, Hindu, educated up to graduate level, homemaker, belonging to a lower middle class socioeconomic status, joint family from Raxaul with TDI 4 days, abrupt onset, continuous course, episode precipitated by SLE presented with c/o fearfulness, delusion of persecution, disturbed sleep and hallucinatory behavior. Patient was uncooperative so Kirby’s method revealed increased psychomotor activities, decreased grooming, uncooperative attitude and no features suggestive of catatonia.

42. Provisional diagnosis Acute and transient psychotic disorder, first episode, currently symptomatic (6A23.00) Points for: Acute onset of psychotic symptoms Delusions, hallucinations Emerged without a prodrome Psychomotor disturbance Absence of negative symptoms Points against: No rapidly changing symptoms

43. Management Investigations:

44. Non pharmacological treatment: Patient and her family members were educated about the nature of disorder, its course and prognosis, need for regular follow ups, need for treatment adherence. Stressful like events and any ongoing stressors to be mitigated with the help of family members. Plan of management during the hospital admission was discussed with the family members. B.P.R.S. 36 at admission, 18 at discharge

45. Brief psychiatric rating scale Somatic concern: 0 Anxiety: 0 Emotional withdrawal: 1 Conceptual disorganization: 0 Guilt feelings: 3-1 Tension: 5-2 Mannerism and posturing: 1 Grandiosity: 1 Depressed mood: 1 Hostility: 0 Suspiciousness: 6-2 Hallucinatory behavior: 4-1 Motor retardation: 1 Uncooperativeness: 6-3 Unusual thought content: 1 Blunted affect: 1 Excitement: 4-1 Disorientation: 1

46. Pharmacological: Tablet OLAZAPINE started 5 mg HS Increased gradually to (5-X-10)mg per day Later c/o daytime drowsiness, entire dosage at night. Tablet LORAZEPAM started 1 mg BD Tapered to stop over 6 days Patient was discharged after 6 days in the ward. She showed significant improvement during discharge.

47. Treatment duration for the 1 st episode of psychosis

48. 1 st episode of psychosis

49. Wunderink L et al (2007). Guided discontinuation versus maintenance treatment in remitted first-episode psychosis: relapse rates and functional outcome. Journal of Clinical Psychiatry, 68:654-61.

50. Published online by Cambridge University Press

51. The American Psychiatric Association Guidelines for the Treatment of Schizophrenia (1997)

52. Canadian Psychiatric Association. (1998)

53. Expert Consensus Panel for Schizophrenia (1996)

54. Lehman & Steinwachs (1998): The Schizophrenia Patient Outcomes Research Team

55. Üçok A. Treatment Principles of First-Episode Psychosis. Noro Psikiyatr Ars. 2021 Sep 20;58(Suppl 1):S12-S16. doi : 10.29399/npa.27424. PMID: 34658630; PMCID: PMC8498813.

56. Üçok A. Treatment Principles of First-Episode Psychosis. Noro Psikiyatr Ars. 2021 Sep 20;58(Suppl 1):S12-S16. doi : 10.29399/npa.27424. PMID: 34658630; PMCID: PMC8498813.

57. References The Maudsley prescribing guidelines in psychiatry 14 th edition, David M. Taylor, Thomas R.E. Barnes, Allan H. Young. American Psychiatric Association (1997). Practice guideline for the treatment of patients with schizophrenia. American Journal of Psychiatry, 154(Suppl 4):1–63. Canadian Psychiatric Association (1998). Canadian clinical practice guidelines for the treatment of schizophrenia. Canadian Journal of Psychiatry, 43(Suppl 2):25S–40S. Expert Consensus Panel for Schizophrenia (1996). Treatment of schizophrenia. Journal of Clinical Psychiatry, 57(Suppl 12B):3–58. Lehman AF, Steinwachs DM (1998). Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophrenia Bulletin, 24:1-10. Üçok A. Treatment Principles of First-Episode Psychosis. Noro Psikiyatr Ars. 2021 Sep 20;58(Suppl 1):S12-S16. doi : 10.29399/npa.27424. PMID: 34658630; PMCID: PMC8498813. Wunderink L et al (2007). Guided discontinuation versus maintenance treatment in remitted first-episode psychosis: relapse rates and functional outcome. Journal of Clinical Psychiatry, 68:654-61.