HISTORY COLLECTION ON OBSESSIVE COMPULSIVE DISORDER
A. IDENTIFICATION DATA:
Name : Mrs.Anitha
Age : 42 Years
Sex : Female
Spouse’s name : Mr. Gopalan
Education : B.Sc.Botany
Occupation : House wife
Marital status : Married
Religion : Hindu
Diagnosis : Obsessive Compulsive Disorder
Address : Vadasery,Nagercoil
Informant name : Mr. Gopalan
Relationship with the patient : Husband
Length of acquaintance : 12 Years
Reliability of information : Reliable and Adequate
B. CHIEF COMPLAINTS:
i) According to Patient:
Patient said, “I have sleep disturbance, obsession to wash hands frequently”.
ii) According to Informant:
Informant said that his wife has the complaints of obsessions of symmetry, sadness, obsession
for frequent hand washing, hopelessness, loss of concentration, disturbed sleep pattern, irritability,
generalized body ache, constipation aggravated for the past 5 days.
HISTORY OF PRESENT ILLNESS:
Duration of total illness is 17 years. Mode of onset is chronic. Predisposing factor is genetic
predisposition. Precipitating factor is conflict with family and husband. Aggravating factor is loneliness
in the home. She was admitted at Sneka mind care centre, Tirunelveli on 20/4/2025 with the complaints
of obsessions of symmetry, sadness, obsession for frequent hand washing, hopelessness, loss of
concentration, disturbed sleep pattern, irritability, generalized body ache, constipation aggravated for the
past 5 days. After investigation like history collection, mental status examination, lab investigation,
psychiatrist diagnosed her to have Obsessive Compulsive Disorder. Now, he is under treatment such as
Tab. Chlorpam 10mg oral bd, Inj.BE Plex1ml IM od, Tab.Protopan 40mg bd, Tab.Amigold 100mg oral
od, Tab. Sertex 100mg oral od, Tab.Erides ER 50mg oral bd.
D. PAST PSYCHIATRIC HISTORY:
She has the history of OCD since 17 years and getting treatment from sneka mind care centre,
Tirunelveli.
E. PAST MEDICAL AND SURGICAL HISTORY:
She had acute appendicitis and undergone lap. Appendicectomy 5 years ago in Holy cross
hospital, Nagercoil.
F. SOCIO ECONOMIC BACKGROUND:
Her mother tongue is tamil. Her husband Mr. Gopalan is the bread winner of the family. Her
house has all the facilities like water, electricity, drainage system.
G. FAMILY HISTORY:
i) Family tree Key:
- Male
- Female
- Married
- Patient
- Deceased male
- Deceased female
ii) Family composition
S. Name of the Age Gender Relation Education Occupation Monthly Health status
No family ship Income
member with the
client
1. Mr.Gopalan 45 M Husband BE Engineer Rs. 30,000 Healthy
2. Mrs.Anitha 42 Fe Self B.Sc.Botany Homemaker Nil Obsessive
Compulsive
Disorder
3. Mast.Adithya 16 M Son 10th Nil Nil Healthy
4. Ms.Geetha 14 Fe Daughter 8th Nil Nil Healthy
iii) Details of family functioning:
She belongs to high socio economic background. Type of family is nuclear family. Her husband
Mr.Gopalan plays a leadership role in the family. There is good communication among the family
members. She had permissive child bearing practice.
H. HISTORY OF ILLNESS IN FAMILY:
Psychiatric :
Her maternal aunt has the history of OCD and she died due to cardiac arrest 3 years ago.
Medical :
Her father has the history of diabetes mellitus, hypertension and her mother has the history of
diabetes mellitus.
I. TREATMENT HISTORY:
Tab. Chlorpam 10mg oral bd
Inj.BE Plex1ml IM od
Tab.Protopan 40mg bd
Tab.Amigold 100mg oral od
Tab. Sertex 100mg oral od
Tab.Erides ER 50mg oral bd.
J. PERSONAL HISTORY:
i) Perinatal history:
Antenatal period of her mother was uneventful. She got delivered as a full term female baby by
spontaneous normal vaginal delivery. She cried immediately after birth. She had no birth complications.
ii) Childhood history:
She had good physical health during childhood except common cold, fever. She was immunized
properly as per national immunization schedule. She had behavioral problems such as thumb sucking,
nail biting, bed wetting. Home atmosphere during childhood was satisfactory.
iii) Adolescent history:
She had no behavioral problems during adolescence such as delinquency, smoking, drug use,
smoking, over weight. There is no parental lack and no habitual absent from home during his
adolescence.
iv) Educational history:
She started her education at the age of 6 years. He studied B.Sc.Botany from holy cross college,
nagercoil. She is a average student in studies. She has She had good relationship with teachers,
classmates.
v) Play history:
He is interested in playing kho-kho, volley ball, carrom, chess.
vi) Occupational history:
She worked as a teacher in the year 21 in a Private school for 3 years. After marriage, she does
not go for work.
vii) Menstrual history:
She attained menarche at the age of 13 years. She has regular menstrual cycle of 28 days with
normal menstrual flow. She used to have back pain during first 2 days of menstruation.
vii) Marital and Sexual history :
She got married at the age of 25 years. Duration of marriage is 17years. Interpersonal
relationship with in laws are unsatisfactory. She had frequent interpersonal conflict with husband.
K. PRE-MORBID PERSONALITY:
i) Social relations:
She has poor relationship with friends, family.
ii) Intellectual activities :
She is interested in playing kabaddi, volley ball.
iii) Mood:
She is a pessimistic person.
iv) Character:
She has poor attitude towards work and responsibility. She has good standards in moral,
religious, social and health matters.
v) Fantasy life:
She has no fantasy life.
vi) Habit:
She likes to eat non-vegetarian foods. She has poor sleeping pattern. She has the complaints of
constipation. She does not have the habit of drinking alcohol, smoking etc.
