Case History – Training Record

Chief complaints:

1. Persistent sadness/low mood since 3 months 2. Excessive overthinking and worry since 3 months 3. Reduced interest in studies and daily activities since 2–3 months 4. Low energy and fatigue since 2 months 5. Poor sleep (difficulty falling asleep) since 2 months 6. Reduced concentration and attention since 2 months 7. Crying spells 2–3 times/week since 1 month 8. Feelings of guilt and worthlessness since 1–2 months

Presenting concerns:

Aanya is a 19-year-old college student experiencing emotional distress for the past three months, characterized by persistent low mood, excessive worry, loss of interest in studies, reduced energy, sleep disturbance, and impaired concentration. Symptoms started gradually after academic stress and family conflicts and have led to withdrawal from friends, decreased motivation, and reduced daily functioning.

Client verbatim statement:

“I feel sad most of the time and I keep thinking too much. I can’t sleep properly and I feel like I’m not good enough. I don’t feel like studying or meeting anyone.

A – Affect / Emotion

Persistent low mood, sadness, anxiety and emotional overwhelm for the past 3 months with occasional crying spells.

B – Behaviour

Social withdrawal, stays alone most of the time, avoids friends/activities, low motivation and increased phone scrolling.

C – Cognition

Excessive overthinking about studies/future with negative self-thoughts (“I’m not good enough”), guilt and poor concentration.

D – Daily functioning

Disturbed sleep, mildly reduced appetite, decreased academic performance, reduced social interaction and irregular daily routine.

Onset details

Insidious / Gradual onset over the last 3 months, triggered by increased academic pressure and frequent family conflicts.

Course details

Continuous course with mild fluctuations; symptoms increase during exams and stressful situations. Overall functioning has progressively declined over time.

Predisposing factors

Sensitive and perfectionistic personality, Tendency to overthink and seek validation, Low self-esteem and fear of criticism, Family environment: strict father, high expectations, limited emotional support, Possible genetic vulnerability (mother has anxiety-like symptoms).

Precipitating factors

1. Increased academic pressure and exam stress 2. Frequent conflicts/scolding at home 3. Feeling of failure and comparison with others 4. Lack of rest and poor coping during stressful period

Perpetuating factors

1. Negative self-talk (“I’m not good enough”) and guilt thoughts 2. Social withdrawal and reduced pleasurable activities 3. Disturbed sleep and irregular routine 4. Avoidance of tasks → more backlog → more stress 5. Excessive phone use leading to procrastination 6. Lack of emotional expression/support at home

Protective factors

1. Good insight and willingness to take help 2. Supportive mother (present for consultation) 3. No substance use 4. Previously good academic functioning 5. Basic self-care maintained 6. Motivation to improve and return to routine

Present maintaining factors

Client’s symptoms are being maintained by ongoing negative self-talk (“I’m not good enough”), excessive rumination and worry, social withdrawal, reduced engagement in pleasurable activities, avoidance of academic tasks leading to backlog, disturbed sleep and irregular routine, increased screen time/phone scrolling, and continued family stress with criticism and high expectations, resulting in reduced emotional support and increased guilt.

Family history

Aanya belongs to a middle-class nuclear family. Father is employed in a private job and is described as strict, short-tempered, and high in expectations, often scolding the client regarding academics and discipline. Mother is a homemaker and is described as caring but anxious and overprotective at times; she tends to worry excessively though no formal diagnosis is reported. The client reports frequent arguments at home, especially related to her studies and performance. There is no reported family history of severe psychiatric illness, substance dependence, or major neurological disorder. Family environment is emotionally stressful with limited open communication about feelings.

Personal history

The client was born out of a full-term pregnancy with no reported prenatal, perinatal or postnatal complications. Developmental milestones were achieved at appropriate ages. Childhood temperament was described as quiet, sensitive, and obedient. She was emotionally reactive to criticism and tended to seek approval from parents and teachers. She has no history of major childhood illness, seizures, head injury, or hospitalization. She reports being generally anxious in new situations and has a habit of overthinking. She maintains basic self-care; however, in the last few months her routine has become irregular with reduced motivation and decreased social interaction.

Educational history

Aanya started schooling at a normal age and studied in an English-medium school. She performed well academically in school and was considered responsible and sincere, though she often experienced exam-related anxiety and self-pressure to score high. She maintained good relationships with teachers and peers earlier. In the past 3 months, her academic performance has declined due to reduced concentration, low energy, lack of interest in studies, and procrastination. She reports feeling overwhelmed by workload and fears disappointing her parents.

Vocational / occupational history

The client is currently a full-time student and is not employed. She has no past full-time job history. She occasionally helps with household responsibilities but finds it difficult to complete tasks due to low energy and poor motivation. No history of workplace conflict or job changes is applicable.

Sexual and marital history

Client is unmarried. No history of sexual activity reported. No history of sexual abuse, assault, or inappropriate sexual experiences. No concerns regarding sexual identity or sexual functioning reported.

Forensic history

No history of illegal acts, police cases, legal disputes, FIRs, or criminal record reported.

Suicidal / self-harm / substance use history

Client denies any history of self-harm behavior or suicide attempts. She denies active suicidal ideation or planning; however, she reports occasional passive thoughts such as “I wish I could disappear” during periods of high stress. No substance use history reported (no alcohol, smoking, or drugs).

Living conditions

Client lives with parents in an urban household. Basic needs and resources are adequately available. Home environment is emotionally stressful at times due to frequent conflicts and high academic expectations. Interpersonal communication about emotions is limited, leading to the client feeling unsupported and pressured.

Premorbid personality

Premorbidly, the client was sincere, responsible, and academically oriented. She is sensitive, perfectionistic, self-critical, and tends to overthink. She seeks approval/validation, fears making mistakes, and becomes anxious under pressure. She had generally good interpersonal relationships but finds it difficult to express negative emotions openly and tends to internalize stress.