Clinical Case Report
Submitted to: Dr. Nabeel
Submitted by: Fajjar Butt (MS
Clinical Psychology 2024-2026
Bio Data Presenting Complaints
Excessive talkativeness (few months)
Name: B
Age: 19 years Aggressive and irritable behavior (6 months)
Sex: Male
Education: 5th standard (discontinued) Difficulty sleeping / insomnia (6 months)
Occupation: Unemployed
Marital Status: Unmarried Overfriendly behavior with strangers (few months)
Religion: Islam
Birth Order: Youngest of 5 siblings (3 Risky behavior: reckless spending, fast driving (few months)
brothers, 2 sisters; one brother deceased)
Socioeconomic Status: Lower; lives with Weakness, numbness, forgetfulness, poor self-care, fearfulness
family in rented house
2
History of Present Illness
For about a year the client has had weakness, forgetfulness,
aggression, fearfulness, excessive talkativeness,
overfriendly with strangers, risky behaviors (reckless
spending, fast driving), sleep disturbance, loss of appetite,
grandiosity, suspiciousness, and poor self-care. Symptoms
have led to family conflict and psychiatric referral.
3
Psychological Assessment
.
•Informal Assessment: Behavioral observation,
Clinical Interview with parents, Mental Status
Examination.
•Formal Assessment: House-Tree-Person (HTP)
Test, Rotter’s Incomplete Sentences Blank (RISB),
Young Mania Rating Scale (YMRS).
4
Mental Status Examination
Appearance/Behavior: Young male, neat, attentive, cooperative but
occasionally resistant.
Speech: Pressured, rapid, loud, topic shifts.
Mood/Affect: Euphoric with grandiosity; irritability and anger present.
Perception: Visual hallucinations, suspiciousness.
Thought: Disorganized, flight of ideas, bizarre/paranoid content.
Cognition: Oriented ×3; slight difficulty with complex tasks.
Judgment: Poor (reckless spending, risky driving).
Insight: Limited, denies illness.
5
Assessment
Findings
RISB Score: 153 (cut-off YMRS Ratings: Elevated HTP Qualitative: small
135) indicates Mood 4, Increased Energy 4, house (feelings of rejection),
maladjustment; conflict Sleep 3, Speech 4, Insight 4 tree with dead branches
attitudes at home and indicates moderate mania. (hopelessness), person
society. drawing shows psychotic
aspects, restlessness, anxiety
6
Case Formulation (Biopsychosocial)
•Predisposing Factors: Aggressive, impulsive personality traits;
low stress tolerance.
•Precipitating Factors: Family conflict, financial stress, loss of
interest in studies.
•Perpetuating Factors: Poor coping skills, poor self-care, lack of
healthy lifestyle habits and support.
•Presentation: Grandiosity, overfamiliarity, hyperactivity,
irritability, risky behaviors.
7
Diagnosis
•Bipolar I Disorder, current episode manic,
moderate with Psychotic features (DSM-5
code: 296.44).
•Personality traits: Impulsivity, aggressiveness,
fearfulness (rule out Cluster B traits).
•No intellectual disability identified.
Prognosis
•Illness started at a young age; high risk of repeated
episodes.
•Left school early, unemployed, poor coping skills, poor
lifestyle habits, family stress.
•Without regular treatment and support, high chance of
recurrence and long-term problems in daily life
9
Proposed Management Plan
•Psychological Counseling and Psychoeducation.
•Anger Management and Deep Breathing techniques.
•Lifestyle Modifications (sleep schedule, healthy diet,
exercise).
•Medication adherence as prescribed by healthcare
provider.
•Building a support network (therapy, support groups,
trusted family/friends).
10
Limitation
• Short time duration for assessment and testing.
• Client’s resistance to explain some incidents
reduced depth of information.
• Lack of a separate, quiet room for sessions.
• Limited cooperation from attendants regarding
sensitive personal information
11
References
•Ayen, E. M. (n.d.). H-T-P (House Tree Person). SlideShare.
https://www.slideshare.net/slideshow/htp-house-tree-person/52723415
•Davis, M. (n.d.). The clinical interview. SlideShare.
•Jain, A. (2023, February 20). Bipolar disorder. StatPearls – NCBI Bookshelf.
•Neukrug, E. S., & Fawcett, R. C. (2010). Essentials of testing and assessment: A practical
guide for counselors, social workers, and psychologists (2nd ed.).
•Voss, R. M., & Das, J. M. (2024, April 30). Mental status examination. StatPearls – NCBI
Bookshelf.
•Young Mania Rating Scale (YMRS) – Psychology Tools. (1978).
https://psychology-tools.com/test/young-mania-rating-scale
12
