Name: Erma Hareem

BS Psychology 2020-24

Case History Report

(Case No. 2)

(Mood Disorder)

(Bipolar 1)

Bio Data

Name: N.A

Father name: M. Ahsan

Age: 40 years

Siblings: 6(5 sisters, 1brother)

Birth order: 2nd last

Sex: Female

Marital status: Divorced

Education: B.A

Socioeconomic status: Middle

Identifying information:

The client is a lady of 40 years old. She belongs to middle class family. Her parents were died. She belongs
to an educated family. Her relation with is good.

Presenting complaints and source of referral:

The client was assigned to me for academic purpose from fountain house Lahore.

According to client brother she was weak and forget things. She becomes sad when can`t done her task.

Interview

information: History

Theclient:
of client was weak. Her behavior with me is good. She is co-operative but has a problem
with concentration. She was looking fresh.

Family History:

Client was 40 years old lady. She lived in Lahore. There is no psychological problem in her family.

Personal History:

The client brother reported that her birth was normal and there is no problem. The problem was started
after her injury in B.A. The symptoms of her psychological illness are crying spells, feeling of guilt,
depressive behavior, sadness, suicidal thoughts

Test Administered:

Clinical interview
Mental state Examination
House tree person (HTP)
Standard progressive matrices (SPM)
Rotter`s incomplete sentence blank (RISB)
Beck depression inventory (BDI)

Behavioral Observation:

According to her brother, her behavior at home is quarrel. She becomes much sad when cannot complete
her task. According to her teacher she was obedient and good student. She was very co-operative. Her
problem starts after her head injury. Her appearance was good and looking fresh.

Interpretation of test`s:

Mental State Examination:

There is abnormal thought pattern in client. Orientation of time and memory is not seems to be intact.
There is suicidal ideation, depression and guilt in her. Her sleep is normal and there is no history of
insomnia. Her movements are normal and mood is good. There is no anxiety and fear in her during
session.

Personality Assessment:

I applied HTP on client for assessing the personality of the client and conflicts in her personality.

Test Taking Attitude:

The test was administered in peaceful environment and in separate room. The client was co-operative.

Qualitative Interpretation:

The images were ambiguous and it shows

Loneliness
Insure
Depends on other
Need care from other
Emptiness
Flexibility

Rotter`s incomplete sentence blank

(RISB) Quantitative Analysis:

Response time C3=6 C2=5 C1=4 N=3 P3=2 P2=1 P1=0

No of scores 2 2 6 4 4 10 12

Obtained score 12 10 24 12 8 10 0

Total score=76

Obtained score=135

Qualitative Analysis:

The total score of the client in RISB is 76 which show that the client is not adjusted in life and need to be
hospitaliz ed.
Standard Progressive Matrices

(SPM) Quantitative Analysis:

Age 40 year

Total score 37

Grade 5

Percentile 5th

Time taken 35 minutes

Intellectual level Intellectually defective

Qualitative Analysis:

The total score of client in SPM is 37 which show intellectually defective in capacity.

Beck Depression Inventory

(BDI): Quantitative Analysis

Raw Score Depression level

0-13 Mild

14-19 Moderate

20-28 Severe

29-more Profound

Qualitative Analysis:

The total score of client in BDI is 5 which show mild level of depression in her.

Diagnosis:

The client is being diagnosis Bipolar 1 disorder manic episode 296.41 (F31.11) due to presenting
complaints.

Prognosis:

The client is satisfied with the re-admission in fountain house and recover her complains due to
recommended therapy.

Recommended Therapy:

Cognitive behavior therapy (CBT)

Session

Report:

Session
In session11, I meet with client and built rapport. Client was frank and co-operative with me.

Session 2

In session 2, I observe the behavior of client her mood was good and told to me all things related to her.

Session 3

In session 3, I take full history of client including her birth and developmental milestone her education,
recreation, hobbies and marital status.

Session 4

In session 4, I applied psychological tests (SPM, RISB) to find out her problem and also checking her
intellectual functioning and adjustment level.

Session 5

In session 5, I applied more psychological tests (HTP,BDI) for checking her personality conflicts
and evaluation also recommended treatment plan for her disorder.