PSYCHOLOGY REPORT

Patient’s Name: KUE, JOANNE C.

Sex: F
Age: 23
Pav/Ward: Pav.2-OPS
Birthday: May 26, 1983
Birthplace: Sorsogon
Civil Status: Single
Educational Attainment: 4th year college Level

Purpose for evaluation:

Subject was referred for psychological examination for presentation at the general staff
conference for diagnosis and management.

Evaluation Procedure:
Clinical Interview
Wechsler Adult Intelligence Scale-Revised Test
Bender Visual Motor Gestalt Test
Draw A Person Test
Rorschach Psych Diagnostic Test
Sach’s Sentence Completion Test
Minnesota Multiphasic Personality Inventory Test-I
Thematic Apperception Test

Behavioral Observation
Examinee is a young adult female who stands 5’5 tall with fair complexion and
slightly robust body structure. She wore a sleeveless shirt paired with low blue hipster
jeans with brown slippers on.
On the first day, she came at this center to determine her intellectual capacity out
of curiosity. She was accompanied by her friends who observed that she was
depressed because she always had an oral argument with her mother. On the second
day of her testing, she was accompanied by her mother who narrated that changes in
her behavior manifested. After having a boyfriend she started to have her own world
and rarely attend to church activities. The mother described her as “malakas ang loob,
mahirap pakibagayan…. Laging nakukuha ang gusto niya kasi bunso siya”. The subject
spent most of her time with her boyfriend but sometime in 2010, she found out that her
boyfriend had another girlfriend through his facebook account. The subject was able to
contact the said other girlfriend and they met. The other girlfriend did not know about
joanne and was shocked about it. Joanne decided to broke-up with her boyfriend of 3
years. In the same year her father passed away due to stroke but prior to his demise,
she and her father has a dispute for her father accused her of telling his illicit affair to
their mother. But she said that it was her eldest sister who saw the text of their father’s
mistress and told about it to their mother. Her father thought it was joanne for she is the
only one whom their father trusted with his cell phone but father did not listen to the
subject’s explanation. Since then she rebelled against her parents for they always
fought and wanted to separate. The subject always got drunk with her friends, then on
day her male friend allegedly raped her due to her unconscious state, hence, she did
not know about it. Until after a month, the alleged rapist called her reminding her about
what happened to them. She was shocked and got paranoid if she was pregnant for she
claimed that it was her first sexual encounter. She admitted that she attempted to
commit suicide, the first was in 2006 she tried to overdose by taking pills due to her
father’s infidelity. She was rushed to Lourdes hospital. The second was when she
thought that she pregnant and drank isopropyl alcohol in September 2010. She claimed
that her eldest sister is verbally abusive to her calling her names which hurt her
emotionally, to the point that she hurt herself by slicing her palm with a knife allegedly to
transfer her emotional pain into physical one.
During the interview and testing session. It was observed that she was every talkative
with good eye contact. But she was not confused in answering the psychological test for
her often text, called the cat and eating during the testing. She was oriented to three
spheres.

RESULT OF EVALUATION
Wais-R Verbal Scale IQ-87
Performance Scale IQ-88
Full Scale IQ-86

Intellectual functioning of the subject is currently assessed in the low average level with
an innate potential of high average. Further analysis reveals her above par in viso-motor
speed while adequately functioning is her capacity for verbal-concept formation and
inductive reasoning. Fairly preserved is her fund of general knowledge, short term
memory, learning ability, numerical reasoning, judgment to reality situation, ability to
anticipate the consequences of initial act and deductive know-how while poor
performance in her keenness in observing details is also noted.

Projective tests reveal a person whose affection longings from her parents are still
ungratified. As a result, ambivalent feeling towards them who are supposed to give her
the care, attention and love that she needed are expressed. Furthermore, she felt that
she is loved by her father who always gives her what she wanted yet she views her
mother as a strict one for she is dominant figure in the family.

She is self-centered, demanding and impatient person who wants to get things right
away without delay for she easily gets disappointed. She is inconsiderate towards
others feelings as long as she can have what she wanted. However, whenever she is
confronted with predicaments, she gets easily overwhelmed with it resulting to her
feelings of anxiety and tension. Initially, she tried to control her emotions but with her
extra sensitivity she is easily provoked by negative feedbacks that an outburst of
emotion is inevitable.

She inter-acts with her social milieu to get the attention that she longs for but on
superficial basis only as she could not establish a deep and meaningful interpersonal
relationship particularly on heterosexual relationship due to the infidelity of her father
and first boyfriend. Although she gets involve with the opposite sex it is only short-lived
because she immediately broke-up from the guys even with slightest negative
behaviour or small wrongdoings in order to avoid getting hurt again and at the same
time retaliate from her first boyfriend.

Basically, she strives to prove herself with others that she is capable to do things on her
own. However, such attitude is a façade merely to cover up her weaknesses. More so,
she lacks personal insight and understanding of her own behaviour so she becomes
defensive about her inadequacy.

Her inflexibility makes her difficult to adjust to new/unfamiliar situations. When others do
wrong against he, she could not easily forget it and she wants to retaliate. When bad
karma is encountered by the person who hurt her, she feels triumphant.

Gender identification and role is adequate but longing to her father’s presence are
noted. She looks forward to achieve her goals in life. She admitted that her greatest
mistake is when she rebelled against her parents and being stubborn. She also felt
guilty when she tried to commit suicide and get involved with a married man. Negative
point of view on the female gender is also elicited.

MMPI is invalid because she admits a lot of symptoms causing marked elevations on
nine (9) clinical scales. She is probably responding to the items carelessly, in a
confusional state or over emphasizing pathology.

TAT stories revolved around a heroine who struggles to achieve her goals in life but
feels confused if she going to follow her mother or does what she wants in life. She
wanted to have her own place where she can feel safe and out of danger. She has good
sister relationship who loves her so much. However, she felt betrayed by her
heterosexual partner who gets involved with another woman when they are still together
until she decides to separate. After the incident, she tries seduce the stranger until they
become secrete lover but still she could not forget her previous boyfriend. When her first
boyfriend tries to come back, she is hesitant to trust him again for she could not forget
the hurt she felt when he had another affair, until the guy stopped pursuing her and later
on they became just friends. She was even left alone by her loved one that makes her
feel sad and tried to commit suicide. Guilt feelings towards her loved one are also noted
as she was not able to say how sorry she was saying hurtful words and ask forgiveness
for the wrong she has done to him. Depression is further noted.

Defences used are evasion, denial, reaction-formation and projection

Reality testing is adequate but other ego functions are weekend. Mood disorder is
entertained.
 Department of Health
National Center for Mental Health
Nuevo De Pebrero St. Mandaluyong City

GENERAL OBJECTIVES:
 To present a difficult and clinically relevant non-psychotic case
 To coordinate with a multi-disciplinary team in aid of producing a concise and
comprehensive history, making the appropriate diagnosis, applying the most
ideal therapeutic regimen and managing the case holistically.

SPECIFIC OBJECTIVES:
 To seek guidance in a diagnostic dilemma
 To present an appropriate psychodynamic formulation and case discussion
 To seek guidance in management and psychotherapy
 To identify and address the difficulties in handling the case

GENERAL DATA:
J.K, a 23-years old female, single, Filipino, Jehovah’s witness, college graduate,
freelance interior designer, born on March 17,1990 in Manila, currently residing in
Mandaluyong city, came alone to seek consult for the first time on July 5, 2013.

PRESENTING COMPLAINTS:
According To Patient:
“Malungkot ako matagal na”
“Di ako naintindihan ng lahat”
“Lahat ng pwedeng gawin, ginawa ko na”

Duration of Illness: since 2010

Sources of Information:
E.K, 62 years old mother, widow, unschooled, homemaker, lives with patient
R.K, 27 years old brother, single, collage graduate, sales agent, lives with patient
L.S., 29 years old friend, single, collage graduate, hairdresser, does not live with patient

The patient was discharged without findings of complication and went back to school to
resume her daily routine at school and home. She passed all her subject while brother
watched over her more closely. The family decided to send her China for Christmas
break. While there, she applied for a job but was unsuccessful. However, she boasted
to her parents that she was a working student. When her sister told her parents that she
was really just touring around china, she was reprimanded for lying and sent back home
in time to attend school in January.
Since then, the patient attended school on weekdays and went out with her brother and
his girlfriend on weekends. She was noted to have difficulty concentrating on her work
plates and unable to pass her requirements on time. She repeatedly asked for
consideration from her professors to undertake extra school activities such as outreach
programs just to pass all her subjects.

Until two years prior to admission (June 2011), the patient’s father became sick,
suffered from stroke and had to stop working as his health deteriorated. On august
2011, the father was admitted in the hospital due to diabetes. The patient and the
mother took turns in caring for her father on top of her school schedule. After a month,
the father passed away due to complications of diabetes. She was not around when the
father passed away.

The patient filed a 1-week leave from school to grieve. She was noted to be sad and
stayed in her room most of the day for about 3-4 days followed by looking for many
activities to occupy her time. At school she joined many extracurricular activities for a
few days then failed to follow through on her commitments. He teachers accommodated
her requests for extended deadlines and postponement of exams until she was ready.
She was able to fulfil the requirements but received barely passing grades. After
attending schools, she went home immediately.

For six months, the patient, along with her mother and brother resumed the daily
routines and got used to the absence of the father. Until, for no known apparent reason,
she started to date again and went to college parties. She was able to pass and
graduate from college.

There were several periods over the summer when she was observed to be sleepless
and would go out of town with friends without permission. Once back home, she noted
be tired and watching TV or sleeping most of the day.

One year and 2 months prior to consult (May 2012), she quickly advertised her
professional interior designing services and attended to many other business projects
similar to her father’s business in printing. She undertook several projects
simultaneously. She was successful in a few designing projects but had to refer the
printing jobs back to her brother. She excessively spent money on clothes, which she
justified as representation costs. She accepted new projects without finishing the
previous ones, causing her failure to deliver some earlier contracts to completion. Her
brother observed that she was seemingly happy at times but then easily irritable at his
long-time girlfriend. She discouraged the brother from getting married and frequently
became irrationally demanding of the brother’s time. Her brother attend. She missed
some work deadline and was noted to be irritable and tried. She then stayed home in
her room most of the day doing work plates that she did not finish. As recorded in her
dairy, she continued to eat more followed by vomiting 3-5 times a week and monitored
her increasing weight. She complained of throat discomfort and continued to work more
on her projects.
One month prior to consult, the patient finished some of her professional
commitments. She continuously ate more sweets than usual when she failed to deliver
some projects. She was persistently concerned about her weight and was seeking
chemical remedies to promote weight loss. She was observed by her brother to be
working too hard but accomplishing less work even if she slept less, stayed home more
often and did not go out at night anymore. He noted that she was gaining weight even if
he did not open up to him anymore thus,

One week prior to consult, the patient’s brother reminded her of her promise to seek
professional help due to the persistence of symptoms. She agreed and consulted at the
outpatient service of Our National Center for Mental Hospital on July 5, 2013.

PAST MEDICAL HISTORY

The patient had incomplete immunizations provided by a paediatrician in USTH. The

patient was hospitalized at 7 years of age for Dengue. She had chickenpox at 8 years of
age. Her mother chided her about the importance of a clear complexion and was made
to be careful to about her appearance. No significant scarring reported.

She was confined for 2 days in Lourdes Hospital on September 27, 2010 for
observation following ingestion of isopropyl alcohol. No complications were found and
was discharged improved. The patient had several consults for throat pain with an
internist in 2011. The diagnosis was undisclosed. She was given antacids
symptomatically. The patient was confined for dengue on July 15, 2013 in Lourdes
Hospital for 1 week.

The patient did not have any history of seizures or head trauma. There was no history of
cardiac, pulmonary, thyroid or metabolic disorders. No history of surgical conditions
requiring consult or confinement. There has no known history of allergy to food or drugs.

PAST PSYCHIATRIC HISTORY

The patient has not had previous consult or has not taken psychiatric medication.

ANAMNESIS

PRENATAL AND PERINATAL HISTORY

The patient’s mother had 3 previous difficulty pregnancies including 1 miscarriage,

where the mother was prescribed complete bed rest from the second trimester up to
term. The patient’s mother was surprised to discover her pregnancy with the patient.

MIDDLE CHILDHOOD
The patient knew she was female at 4 years of age preferring dresses and stuffed toys.
She had a special stuffed bear and blanket that she turned to when she cried. She still
has these objects to this day. Primal scene was not witnessed.

The patient had her earliest memory at 5 years of age when her mother was running
after her around the house with a ruler and she fell. She sustained a painful abrasion on
her knee and her mother took care of her wound instead. With one stern look from her
mother, the patient behaved, fearing punishment.

The patient grew up in the 2nd floor of a house owned by the father’s family. The printing
press in the first floor of the house was supervised by a paternal uncle on the weekdays
and supervised by the father on the weekends. During weekdays, the father had a
managing position in an appliance center. The mother went to the market every week
and cooked the daily meals. Catholic holidays were not observed. The family just stayed
home together with the mother cooking a special meal. On birthdays, gift were not
given. The father gave extra money to the mother to cook a preferred dish.

The patient entered preschool at 5 years of age in the same school as her siblings.
Preschool was only half-day but she stayed up to the dismissal time of her siblings in
the afternoon. This was done to save on transportation costs, accompanied by a helper
and driver. She played around the campus and waited with the helper who brought
lunch and snacks. No separation anxiety noted. She easily made friends in school,
described as a leader more than a follower. She did not have any best friends she
followed the rules in the school. No conduct problems or learning disabilities noted.

The parents compared the patient to her sister. The sisters excelled academically while
the patient was fond of sketching, drawing and playing outside. The sisters were then
instructed to teach her the lessons and homework at home. They were strict in teaching
her assignments and used the same wooden stick that the mother had used to punish
her. She awaited her father’s arrival home to find a reprieve. No nightmares, phobias,
cruelty to animals reported.

LATE CHILDHOOD

The patient’s home was the 2nd floor of a house, which did not have any dividers except
for the bathroom. At night they all slept together in one room in separate beds. At 14
years of age, separate rooms were built and the patient got her own room.

The patient participated in cheer dancing and the volleyball team. She at whatever she
wanted since she had many athletic activities to attend to. She had several friends from
different groups with no close female or male friends. She was proud of her athletic
ability and put less importance on her academics, which she passed. She did not like
being compared with her sisters who were studious. No intense sibling rivalry reported.

The patient experienced menarche at 14 years of age, irregularly occurring cycles at 28-
90 days interval, 4-5 days duration, soaking 2-3 pads per day, with dysmenorrhea on
the first day, and intake of analgesics for symptomatic relief. She learned about
menstrual hygiene in school. Last menstrual period June 25-29, 2013.

The patient had her first sexual experience on August 2010 with a 27 years old resort
manager and a friend of her brother. She had only met him once and was warned by
her brother that he was a heavy drinker, unlike the patient. The patient was brought to
the date’s apartment after drinking heavily in a restaurant. She was brought home at
sunrise the next day as reported to the brother the next day. The patient was not called
on again by her date. A mother later, the same man called her over the phone. She
spoke to him and then got angry. She went to her room where she stayed for 2 days.
The brother talked to the patient to whom she confessed drinking isopropyl alcohol. She
told her brother that she had been date raped by the man who called her. Her brother
was not convinced. No charges were filed.

RELATIONSHIP HISTORY

The patient sought social and financial stability in relationships ultimately leading to
marriage. She met her first boyfriend through her brother’s first and only girlfriend from
the church. On weekends, she double date with her boyfriend, her brother, and his
respective girlfriend. In the 3 years of an exclusive relationship, no sexual intimacy
occurred. On March of 2010, she told her boyfriend that she needed to concentrate in
her finals so she told him that they needed time apart. A month later, she found out
through social networking that he already had another girlfriend. She contacted the new
girlfriend to confirm the news. When the new girlfriend confirmed the news, she made
efforts to cause a break-up by disparaging his reputation; however, she was
unsuccessful. On the same day, the boyfriend asked her out for dinner and told her that
he already had a new girlfriend.

The second boyfriend was a print ad model in the summer of 2011 for 2 months after
her father’s death. She enjoyed the social exposure she experienced. No sexual
intimacy ensued and the relationship ended and the relationship ended due to the
boyfriend’s busy schedule.

The third boyfriend was a manager of an automotive repair shop from November 2012
to February 2013. She had 5 sexual encounters with him. She ended the relationship
because he was not Chinese. Her mother and brother did not approve of him.

The fourth boyfriend was a Chinese automotive repair shop owner in March-April 2013.
She did not know that he was a married man and had 2 sexual encounters with him.
Once she and her brother found out that he was a married man through a common
friend, she ended the relationship.

SOCIAL ACTIVITIES
The patient enjoys going out with friends of her brother. She has a few friends close
friends from work. She finds it difficult to trust women.
FAMILY MEDICAL HISTORY
No history of known mental illness in the family. No history suicide attempts seizures or
drug use in the family.

The father was diagnosed with hypertension and diabetes and died of complications of
heart disease in 2011. No history of endocrine, cardiac, pulmonary, renal or metabolic
diseases in the family.

FAMILY PROFILE

PARENTS

E.K, 62 years old, mother, widow, unschooled, homemaker

“saludo ako dyan, sa dami ng pinagdaanan, malupit, may sakit na siya”

R.K., father, deceased at 66 years, college graduate, entrepreneur

“walang pakialam, maabilidad kung may kailangan, binibigay, tahimik”

PARENTS MARITAL HISTORY

The mother was orphaned at a very young age and taken in by Chinese relatives. The
mother was unschooled and learned to survive in the streets by vending food at 7 years
of age. The mother was welcomed into the faith of Jehovah’s Witness at 12 years of
age and taught to read and write at 16 years of age by her elders. At 17 years of age,
she worked in a printing press where she met the son of the owner who was 6 years her
senior.

Both into their first relationship, the family of the patient’s father disapproved of the
mother due to her lack of Chinese lineage and education. The father supported the
mother secretly after the mother was made to leave the printing press. The family
eventually relented and the parents were married after 10 years together. Due to the
living arrangements, the parents had physical intimacy only during daytime when the
children were away at school.

The father was a quiet man who regularly gave weekly allowance to his spouse for the
household expenditures. The wife was not to ask questions about his activities or how
money was made and spent. She was not involved in the paternal family business. In
2006, the mother was informed that her spouse was allegedly supporting a young
woman as evidenced by messages on his mobile phone. The marriage was
troublesome until 2008 when the martial relationship was restored.

Neurological Examination
Motor: 5/5 in all quadrants
Sensory: 100% in all quadrants
Reflexes: ++ in all quadrants

Laboratory Examination
Complete blood count: July 16-22, 2013 (Lourdes hospital)
Serial platelet count: 220, 180, 120, 160, 105, 167
Urinalysis: within normal limits
Na, K, CL, HCO3: within normal limits
TSH, FT3 AND FT4 requested and awaiting results

Dental examination: July 25, 2013

Dental carries, no mucosal lacerations, enamel density could not be assessed

Course in the OPS

1st OPS CONSULT (JULY5, 2013)

The patient was seen and examined as a well kempt and groomed, cooperative, young
adult lady with minimal make up, clear and fair complexion, of Chinese descent, of
medium frame and build, wearing blue v-neckline shirt, and light blue jeans with hair tied
back. She initially had a hunched posture then she became more comfortably seated
after a few minutes after introductions were made. She had good eye contact. She
spontaneously brought up the reason for her consult: that she needed to talk to
someone about her problem that all started in 2006. She had an elevated mood with
appropriate affect. She had occasional pressured speech and racing thoughts about her
childhood. Her self-esteem was elevated and at times easily distracted. She admitted
previous hospital confinement for dengue in childhood and chemical ingestion in 2010.
She denied any surgical procedures, any illicit drugs intake or any recent alcohol or
nicotine use. She denied any instance of auditory hallucinations. No grandiosity or
psychomotor agitation/retardation noted.

She recalled has been sad and unsatisfied with her life since her father falsely accused
her in 2006 for destroying the family but that she was able to cope with it by increasing
activities in school. She mentioned she was really sad and angry with herself for losing
her first boyfriend. She described about a month of sleeplessness, described as
terminal insomnia, poor appetite that led her to lose weight, feelings of fatigue and
sadness in all her activities, worthlessness about herself, and hopelessness about her
future at the time.
She was slumped on the table, smiling with soft laughter. She commented that she was
exhausted from all the questions in psychological service. When her mother started to
talk about being a Jehovah’s Witness, the patient seemed annoyed. When her
annoyance was acknowledged, she straightened up her posture and dismissed her
mother whom she instructed to go home.

Seen and examined an adult female, well kempt and groomed dressed in a red printed
dress, finger nails groomed with red nail polish, muted make-up using prominent eye
liner. Her mood was elevated with appropriate affect. She spoke norm productively in a
well-modulated voice. She looked up the ceiling and sighed after her mother left. She
re-established good eye contact and narrated wistfully that she never really trusted
women in general but she was only honest about her whole life now because she would
never have to return to therapy one she fixed all her issues. She also mentioned that
she would refuse any medications from the service until she was convinced about her
psychiatric evaluation.

She really wanted to know why her past relationships with men were failures and why
people thought so little of her. She was especially bothered that a married man
deceived her. She earnestly asked: “bakit ba… ano ba ang tingin sa akin?” she said she
really thought that the man she had her first sexual encounter with was the one she was
supposed to marry. She admitted guilt about her sexual indiscretions in relation to her
religion. She said it was up to her to practice her faith and seek forgiveness.

She claimed that she wanted people to think she was strong. She traced her past
experience in dealing with pain when she was 5 years old. She recalled one time when
she was terribly afraid and running away from her mother who was running after her to
hit her with the ruler. When she fell down and hurt her knee, her emotional pain was
relieved by the physical pain, which caused her mother to care for her. She could not
explain how her had mother hurt her emotionally. She claimed that she was not close to
her mother at present and that she had mixed feeling about her mother.

She described her mother as being distant, cold and unavailable. She quickly added
that she admired her mother for all the adversity the latter had encountered being an
orphan. She complained that the mother prioritized church activities more than her
when she was growing up. She says she wants to be close to her mother except the
latter always compares her to her sisters. She admitted being jealous of her sisters
because of that. When asked if she had forgiven he sister for falsely accusing her,
leading to her broken relationship with her father, she looked away, frowned and said
“never… what for pa?”
She admitted guilt and blamed herself still for the loss of her father before she could
complete restore their relationship. She missed him and resented him at the same time
for not believing her in 2006. She said that it was only her brother who understood her
then, but at present, she could not talk freely to him anymore.

When asked why her voice seemed hoarse that day, she revealed that she had been
inducing herself to vomit to be thinner. She admitted that she was so afraid of being fat.

On the 4th ops visit (July 25, 2013) interview with the supervisor
Seen and examined an adult female, pale complexion, clad in a white oversized polo
and black leggings. She was seated calmly with crossed legs with her hands holding the
bag on her lap. Her mood was euthymic with appropriate affect with norm productive
speech. She said her main reason for consult was that “I may look happy outside, but
inside, I’m not” she mentioned she could not tell her kuya everything.
She claimed that she had a perfect life and perfect family until 2006 when she and her
sisters started fighting and her parents were also quarrelling. She said since then, were
no more family vacations and the family was never happy together. She admitted she
had made her first suicide attempts 2006 by superficially slashing her wrist at the
creases so no one would know. No medical complications reported until her second and
last attempt in 2010 by chemical ingestion.
She said her unhappiest moments in life were: when her mother or sisters fought her
and upon the death of her father while the happiest moments in her life was when her
family was complete. She said she had become mentally and emotionally weak since
the father’s death and that she coped with her sadness by staying home watching TV or
when on the computer. When asked how she expresses anger she answered that she
does so quietly; specifically, she will not confront directly but the person will feel her
wrath somehow. She said she had only few friends because she avoided them when
she felt she could not trust them. “umiiwas ako, at sila din umiiwas sa akin, so iiwan ko
sila….ako na lalayo.’

She elaborated that she had mood swings in a matter of hours to few days, where she
would spend and shop relentlessly, drink alcohol described as “come on…on the move
palagi.” She added “lahat sasabihin, lahat gagawin in a matter of hours, tapos…sobrang
depressed na ako. Sa kwarto lng ako,” she said people saw her as “masayahin, I don’t
break easily, parang masaya pero hindi.” When asked how she saw herself, she said
she was mature. She admitted that in the future, she wanted to change physically to be
thinner and to change her attitude. She denied any perceptual disturbances and she
had fair impulse control with fair social and test judgment.

No medications were given and she was requested bring her next CBC that was
scheduled after 2 weeks by the attending medical physician. She denied that she has
been inducing herself to vomit this week and promised to attend the conference on
August 1, 2013 as long as her schedule permitted.
Defences used are evasion, denial, reaction-formation and projection.

SALIENT FEATURES
THOUGHT:
Morbid fear of being fat
Drive for thinness

MOOD:
One severe depressive episode
Elevated mood followed by depressed mood in less than 1 week occurring 4 times a
year
Increase in goal – directed activity
Increase in activity that leads to pain
Rapid mood shifts within the day

BEHAVIORAL:
Attempted suicide
Periods of uncontrolled eating followed by induction of vomiting 3/weeks for 1year
Sleeplessness
Increased activity followed by fatigue in less than 1 week

SOMATIC
Throat pain, fever, bleeding tendencies

FUNCTIONALITY
Occupational functioning is affected over time
Impaired sibling relations

DIFFERENTIAL DIAGNOSIS
Mood disorder due to a general medical condition
Mood disorder due to substance use
Schizoaffective disorder
Borderline personality disorder
Severe depressive episode, without psychotic symptoms
Bipolar affective disorder, current episode manic, without psychotic symptoms
Bipolar II disorder, current episode hypomanic
Bulimia nervosa, purging type
MULTIAXIAL DIAGNOSIS
Axis1: 296.89 bipolar II disorder (recurrent depressive episode with hypomanic features
without psychotic features)
307.51 bulimia nervosa
Axis2: none
Axis3: none
Axis4: poor relationship with mother and siblings
Axis5: GAF on first consult and present (61-70)
ICD – 10 Diagnosis
F31.8 other bipolar affective disorder
F50.2 Bulimia Nervosa, purging type

Discussion
The clinical marker for bipolar II disorder is the history of no-psychotic and non-
disruptive variants of mania, known as hypomanic episodes. Marked impairments in
functioning does not occur and there are “sunny” variants of hypomania described as a
boost in energy and self-confidence and the darker variant of hypomania in which
irritability, impairments in interpersonal and occupational functioning does occur over
time. DSM-IV-TR stipulates a minimum duration of 4 days but recommends a threshold
for detecting the duration of hypomania be set 2 days. Thus the duration of hypomania
is less important than the fact that they do recur that even if their duration is 1 day
interspersed with major depressive episodes is presumptive evidence of Bipolar II
disorder. Studies show that patients with a diagnosis of bipolar II disorder will have the
same diagnosis up to 5 years later. It is a chronic disease that warrants long-term
treatment strategies. Suicide attempts carry a greater risk and are more successful in
bipolar II Disorder than in Bipolar I Disorder

MANAGEMENT
The core treatment goals: (1) attaining and maintaining a healthy and individualized
stable body weight (2) stopping abnormal eating behaviors: binge eating or purging (3)
dismantling the core overvalued beliefs and unhealthy cognitive “schemas” of automatic
cognitive distortions, replacing them with healthy, balanced views of self (not primarily
dependent on body weight or shape) and the capacity for emotional and behavioral self-
regulation; (4) treating the bipolar II disorder and Dengue Hemorrhagic fever (5)
planning for ongoing relapse prevention for approximately 5 years after acute
improvement. Other methods of treatment include medical, nutritional, educational,
psychotherapeutic, behavioural and psychopharmacological. In a 10-years follow-up
study of patients who had previously participated in treatment programs, the number of
women who continued to meet full criteria for bulimia nervosa declined as the duration
of follow-up increased.

Proposed Treatment Plan:

Short Term Management
Supportive psychotherapy
Cognitive behavioral therapy (14-16)
Identifying cognitive distortions
Family education
Nutritional support and education

Long Term Management

Pharmacotherapy
Supportive psychotherapy
Interpersonal therapy
Family therapy
Nutritional education