CASE FILE FORMAT

PSY 9
CASE SUMMARY REPORT

I. BASIC/ IDENTIFYING INFORMATION

 Name: J. G. N. E.
 Gender: Female
 Age: 23
 Birth order: 2nd born

II. BACKGORUND OF THE CASE/PSYCHOSOCIAL HISTORY

 Strength and weaknesses of the client relevant to the case

In terms of strength the client has good insight when it

comes to her disorder, she is well aware that she is not in good
condition and she needs help. The client also knows how to draw
and can play multiple musical instrument such as the piano, the
guitar and the flute. The client solely depends on God when it
comes to her disorder, she reported that every time a voice
whispers within her head telling her to do something bad, she just
pray till the voice fades, praying is her way of coping. The client’s
weakness is her cognitive impairment, she showed signs of long
term memory problem, she also appears to have a distracted
attention, and in addition the lack of motivation is present. The
client has no plans for the future. She also stated that she can
understand animals.

 Health history since birth/Recent Status

The client reported to had abuse several kinds of illegal

drugs, alcohol, as well as abortion pills. The client reported no
disorder originating from her family background. The client have
experienced pregnancy but often fails to deliver the child due to
abortion. The client reported that she is suffering from bipolar
disorder, she explained that when she experiences her episodes she
would feel extreme sadness or happiness, visual and auditory
hallucinations are also present. The client stated that she is now
feeling much better within the institution, she occasionally
 experiences her episodes and the voices and images are rarely
experienced.

 Academic History/occupation history/recent Status

The client was able to finish her 1st year in high school, she
reported to have work as a dishwasher. She is now a resident of a
certain mental institution.

 Family background

The client’s father is a memorial mason and her mother

died due to kidney failure, the client has two siblings, jovi a lesbian
who is also the oldest and Joshua as the youngest. The client and
her siblings was brought up by their grandmother. The client
reported that she had no quarrel with any member of the family,
although she stated that she experienced her symptoms when her
mother passed away. The client stated that her mother would only
raise her hand on her and her siblings when it comes to disciplining
them, and such action was only possible because the mother was
stressed out due to her ailment. The client reported no kind of
abuse originating from any member of her family, she addressed
them all as “mabait”. Now that the client is residing in a mental
institution her father and grandmother would occasionally visit her.
The biggest regret of the client when it comes to her family was
her negligence of their advices.

 Stressors

The main stressor of the client are the memories of her past,
recalling past memories made the client uncomfortable, when
asked about the details of her abortion the client suddenly looked
down and immediately looked backed up at the interviewers and
exclaimed “huh?” as if no question was asked. These past
memories includes the clients romantic and sexual relationships,
her memories of her peers that taught her how drink alcohol and
use illegal drugs, the time when she disobeyed all of the 10 ten
commandments, includes stealing and murder via abortion.
 Behavioral observations

At the beginning of the interview, as the client slowly

approached the interviewers, she appeared anxious, cupping and
rubbing her hand for the duration of the interview. The client was
neat, her hair was long and black and was tied appropriately. Her
complexion was pale though she looked healthy for her age. She
was soft spoken and can maintain eye contact, although anxious
she was cooperative, trying her best to answer every question
asked, her attention is not fully focused on the interviewers but
there are no hallucinations, both auditory and visual hallucination
are not present for the duration of the interview.

 Other relevant information

The client was greatly influenced by her peers, she learned

how to use illegal drugs and consume alcohol at a young age, and
also it is because of her peers that the client neglected her studies.
The client stated that she disobeyed all of the 10 commandments,
she explained that stealing is one of the things she could not
control, according to her, her hand moved on their own, also when
asked how many times she committed abortion the client replied
”marami na” while giggling in an embarrassed way.
The client experience coitus at a young age, she stated that men are
untrustworthy, she often fell in love and left ruined. When asked
who she feel closest to, the client answered that it is God, God
provides everything for the client as she claimed, and God
answered most of her prayers including her prayer about eating her
favorite foods.
The client also reported that her symptoms manifested after
the death of her mother, although when asked on the latter part of
the interview the client stated that her symptoms were present
since she was in her childhood, but her mother passed away when
she was fifteen years old.

 Basic functioning profile

The client functioned normally in terms of motor activity,

on the other hand the client exhibit a slight problem when it comes
to her cognitive functioning, her memory both short and long term
are somewhat questionable, she was asked multiple times with the
same question and her answers were inconsistent, also she did not
notice about being asked with the same question again and again.
 III. REASON FOR REFERRAL/CONSULTATION

The client was experiencing sudden changes in moods

experiencing extreme happiness and sadness, also presence of
hallucinations is reported, both visual and auditory. The client was
diagnosed with Bipolar disorder.

IV. SOURCES OF INFORMATION ASIDE FROM APPRAISAL

MEASURES CONDUCTED AND ADMINISTERED

The main source of information gathered was through

interview and mental state examination. Usage of any standardize
or projective test were not allowed due to ethical principles and
lack of the student’s ability and mastery to utilize such tools.
Access to the client’s records were also prohibited.

V. APPRAISAL MEASURES CONDUCTED AND ADMINISTERED

MENTAL STATUS EXAMINATION

A.) APPEARANCE

Our Patient was the only one who has a shoulder length hair. She was shy and anxious as
she approached us. She was very cooperative during the interview but sometimes
guarded depending on the questions (intimate relationships and abortion). Generally, our
patient is well groomed. She was clothed by a gown provided by the institution. She
appeared healthy.

B.) SPEECH

The patient can communicate normally, there were no signs of any speech impairment.
She was soft spoken.

C.) MOOD AND AFFECT

MOOD: The client’s mood for the duration of the interview was anxious, her hands were cupped
together and she were rubbing them together for the duration of the interview.

AFFECT: The affect of the client was restricted, although cooperative she was not disclosing all
vital information, especially when it comes to her past.

D.) THINKING AND PERCEPTION

FORM OF THINKING: The patient’s story and answers are connected and essential.
Her ways in putting her thoughts together is fine.

CONTENT OF THINKING: There were no preoccupations about obsessions,

compulsions, phobias, suicidal ideation, antisocial urges or impulses.

THOUGHT DISTURBANCES: The patient believed that her mother is in another planet.

PERCEPTUAL DISTURBANCES

The patient claimed that she hears 3 different voices whispering to her and she can
understand animals, in addition she can also see a headless man.

E.) SENSORIUM
1.) ALERTNESS:
During the interview, the patient was alert enough and was able to answer
immediately.
2) ORIENTATION:
The patient was able to give us her name and can wrote it without hesitation and
she knows where she is because since she was a child, she mentioned that she
visits there for check-ups. A
3) CONCENTRATION:
[We were not able to gather information about this.]
4) MEMORY
o IMMEDIATE
[We were not able to gather information about this.]
 o RECENT
The patient was able to answer questions regarding about her recent life
inside the institution; she was able to tell us who is her closest friend
inside.

o LONG TERM
The patient’s long term memory is impaired for the reason that her
answer regarding about her past life were inconsistent.

5) CALCULATIONS: [We were not able to gather information about this.]

6) FUND OF KNOWLEDGE: [We were not able to gather information about this.]
7) ABSTRACT REASONING: [We were not able to gather information about this.]

F.) INSIGHT

The patient is fully aware of her mental illness.

G.) JUDGMENT

The patient is aware of the likely outcome of her behavior so in able to avoid those, she
mentioned that she just pray to God for guidance.

H.) SUMMARY OF FINDINGS

The patient is somewhat like all the young adult except that her long-term memory is not
reliable and she has an auditory hallucinations as well as visual and she has a bipolar
disorder.
VI. ANALYSIS/EVALUATION/DIAGNOSIS OF THE CASE

Utilizing the Diathesis-stress model allowed me to come

into conclusion about the client’s problem. The client have been
abusing drugs that may have caused the disorder. In terms of
psychological factors the hallucinations are clear signs of the
client’s problem, but the biggest stressor may have been the
individuals past experiences that lead to the manifestation of her
symptoms. The client’s relationship with her peer may also have
played a part in the manifestation of her disorder.

Diathesis Stressors Disorder

Biological Biochemical Substance
Factors Imbalance Abuse

Psychological Pyschosis Hallucination Substance/Medication

Factors induced-Bipolar
Suppressed Traumatic Disorder
Negative experiences
Memories

Social Peer Influence Peer pressure

Factors

VII. CASE CONCEPTUALIZATION

Psychoanalytic Social Theory

The client was brought up by her grandmother that may

have been the reason for the lack of genuine love that the parents
should have provided, as Horney stated that lack of genuine love
causes neurotic conflicts that stemmed from an individual’s
childhood. Due to the lack of genuine love the client experienced
basic hostility which in turns leads to the formation of basic
anxiety. With the presence of basic anxiety the client needed to
protect herself, she relied solely to submissiveness resulting to the
neurotic trend “moving towards people” allowing her peers and
other people to exploit her that leads to drug abuse and unwanted
pregnancy. Due to the lack of genuine love and the presence of
drug abuse, the client experienced intrapsychic conflicts in the
form of idealized self-image and self-hatred that may have been
the reason for the manifestation of her disorder.
VIII. TREATMENT PLAN

A comprehensive bipolar treatment plan involves:

Medication – Medication is the cornerstone on bipolar disorder
treatment. Taking a mood stabilizing medication can help minimize
the highs and lows of bipolar disorder and keep symptoms under
control.
Psychotherapy, or "talk" therapy, is an important part of
treatment for bipolar disorder. During therapy, the individual can
discuss feelings, thoughts, and behaviors that causes problems.
Talk therapy can help understand and hopefully master any
problems that hurt the individual’s ability to function well in life
and career. It also helps the individual stay on her medication. It
can help maintain a positive self-image.
 INTAKE INTERVIEW
By: Castillo, John Albert Matthew V.
Date: October 12, 2017

I. DEMOGRAPHIC INFORMATION

Name: JGNE Nickname:

Date of Birth: _______________ Age: 23 Sex: ( ) Male ( ⸝ ) Female

Marital Status: ( ⸝ ) Single ( ) Married

( ) Partnered ( ) Separated
( ) Divorced ( ) Widow/er

Complete Address: __________________________________________________

Phone: ______________________
Mobile: ______________________
E-mail add: ___________________

Highest Educational Attainment: 1st year high school

Occupation: ____________________________
Company: _______________________________
Position: ________________________________
Company Address: ___________________________________________________

Referred by: _________________________________________________

Reason for Referral: Substance/Medication-Induced Bipolar
II. PROBLEM ANALYSIS [Patient’s Point of View]

PROBLEM DESCRIPTION: What are your main concerns? What is it that made you
decide to seek the help of a psychotherapist? Could you describe the problem/s you wish
you had the most help with right now?

Bipolar

INITIAL ONSET: When did the difficulty first begin?

Nung namatay nanay ko

FREQUENCY: How often does it occur? Have there been any changes in how often it has
occurred?

Nagdadasal na lang ako kapag sinusumpong ako tsaka kapag

ANTECEDENTS/CONSEQUENCES: What usually happens before the difficulty/problem

present itself? In what context or situation does it usually occur? What happens after the
behaviour/s occur/s?

Nagwawala ako. Tinatapon ko yung mga gamit naming sa bahay. Tapos may mga
bumubulong sa akin, tatlo sila. Nagdadasal na lang ako para mawala sila.

PROBLEM INTENSITY: How would you rate the intensity of the problem or concern that
you brought in?

1 2 3 4 5 6
Not intense Extremely
intense

PROBLEM DURATION: Approximately how long have you had the current problem?
 Simula nung mamatay mama ko / Nung highschool ako /Simula nung bata ako

EFFECTS: In what ways has this problem affected you?

Di ko makontrol sarili ko nagbabago bago mood ko.

COPING ATTEMPTS: In what ways have you attempted to cope with this problem?

Nagdadasal na lang ako kay God tapos nagbabasa ako ng bible.

PREVIOUS TREATMENT/FORMAL TREATMENT: Is this the first time that you have
consulted the help of a mental health professional? If not, then whom did you seek previous
treatment from? What was the outcome?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______________

III. FAMILY BACKGROUND

1. Tell me about your family of origin. Kindly describe each family member in terms of
their personalities, intelligence, the role each person played in your upbringing, as well as
your current relationship with each of them.

Mabait naman silang lahat. Yung ate ko, tibo tapos yung bunso namin lalaki magkasunod
lang kami ng edad, 22 siya. Yung lola ko nagpalaki sa amin pero ngayon hindi na kasi may sakit
na siya sa kidney. Yung mama namin, mabait din, inaalagaan niya rin ako pero masungit siya
kapag may sakit siya.

2. What do your parents do for a living? Can you describe their lifestyle? What kind of
activities do they engage in?
 Wala na si mama eh, baka nasa kabilang mundo na. Si papa asa bahay, minsan binibisita
niya ako dito kapag pasko o kaya new year.

3. Could you describe to me the neighbourhood where you grew up? How about your
home environment? Give me a good picture of the various households in which you have
lived.

Mabait naman mga kapit-bahay namin.

4. Are your parents still married or are they separated? Could you describe their
relationship to each other?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
________________

5. How would you describe the way your parents brought you up? Were they particularly
strict, punitive, or tolerant of your behaviour? How would you describe their parenting
style?

Lola ko nagalaga sakin eh. Mabait naman siya.

6. How would you describe your relationship with your mother?

Okay naman, masungit lang siya kapag may sakit siya.

7. How would you describe your relationship with your father?

Mabait.

8. Whom were you particularly close to?

Kay God.
9. Whom did you have the most conflicts with?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______________

10. Tell me more about your siblings?

Tomboy si Jovi siya ung panganay at si Joshua yung bunso

11. Do you know of any major medical or psychological problem/s in any of your family
members? What is your parent’s current state of health and well-being?

Wala naman.

12. Who in your family do you currently feel closest with? most distant with? in most
conflict with?

Kay lola ako pinakamalapit.

13. With regards to your current difficulties, do you think your family members are
supportive, indifferent, or destructive?

Okay lang naman, binibisita naman nila ako minsan.

14. How much is your family a source of emotional support for you?
( ) none ( ) little ( ) somewhat ( ) substantial ( ) very strong

IV. PERSONAL HISTORY

1. Can you recall descriptions or stories about you as a baby? Did your parents mention
signs of behaviour problems during your early childhood? What was your temperament
and personality as a child?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______________

2. Did you have friends in school? Kindly describe to me your social relationships during
this time.

Meron, mabait sila sa akin.

3. Can you tell me about your peer relationships during from prepuberty through
adolescence? Do you have many friends during this time and how close were you to them?

Okay lan.

4. Were you popular in school? Did you belong to a particular group/clique? Describe this
group that you belong in. Did you participate in group or gang activities?

Naglalaro kami dati ng volleyball tsaka badminton sa school non.

5. Did you have role models this time? Were there people you idealized or idolized?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_________________
6. Did you have a particular emotional or physical problem when you were an adolescent?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_________________

V. EDUCATIONAL BACKGROUND
1. What schools did you go to?

Sa bulacan ako nag-aral.

2. Did you encounter any problems, whether academic or relational, when you were a
student? How did you perform in school?

Sakto lang naman mga grades ko, okay lang.

3. What were your other interests when you were a student? Did you engage in sports or
were there advocacies that you were particularly active in during this time?

Naggigitara ako noon, flute at piano. Tinuruan ako nung bespren ko.

4. How would you describe your relationship with your classmates? Teachers?

Ok naman mababait sila.

5. Did you have any difficulty in any of your school subjects? In terms of academic
achievement, in which areas did you excel as a student?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______________

VI. SEXUAL DEVELOPMENT

1. Would you describe to me your earliest curiosities regarding sex?

______________________________________________________________________________
______________________________________________________________________________
__________
2. What were your feelings regarding sex when you were in your puberty?
______________________________________________________________________________
______________________________________________________________________________
________

3. When did you first have your menstruation and what did you feel about it?
______________________________________________________________________________
______________________________________________________________________________
________

4. Let’s talk about your attraction to people. Are you attracted to the opposite sex, to the
same sex or both? Lalaki

5. Did you go on dates? Oo

6. What was your recollection of having your first crush in school or in your
neighbourhood?

Dati nagkaka-crush ako.

7. Have you ever engaged in any form of sexual activity in the past? How did you feel
about it?

Oo.

VII. ADULTHOOD

1. Can you describe your religious background? What are your current religious practice?

Catholic ako. Pero nakapunta na ko sa, born again, INC tsaka sa iba pa pag iniinvite ako
ng mga kaibigan ko.

2. Is spirituality important in your life? How do you express your faith and spirituality?
 Oo. Nagdadasal ako tsaka nagbabasa ng bible.

3. Can you tell me something about the different jobs held in the past?

Tagahugas ng pinggan sa karinderya tsaka naglilinis ng bahay. Pero hindi ako tumatagal,
mabilis kasi ako magsawa, kapag ayaw ko na, di ko na pinupuntahan.

4. What is your relationship with authority, peers, and subordinates at work?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________

5. How many jobs did you have in the past and what were their durations?

Marami. Pero hindi ako tumatagal, mga isang buwan siguro, mabilis kasi ako magsawa.

6. What is your current job and how do you feel about it?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________

7. Do you have friends?

Oo.

8. What are your social, intellectual, and physical interests?

Mahilig ako magbasa ng pocket book at naglalaro din ako dati ng volleyball at
badminton.

9. Can you describe to me your romantic and/or sexual relationship with the same or
opposite sex?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________

10. Can you tell me something about the depth, duration, and quality of relationships you
have with important people in your life right now?

Mabilis lang kasi nga nagsasawa ako agad tsaka niloloko nila ako.

11. What are your career ambitions?

Gusto ko maging teacher pag labas ko dito.

12. Are you married? Can you tell me more about your spouse? Describe your relationship
with your partner. What are the areas of agreement and disagreement between you and
your partner?

Wala.

13. What are your attitudes towards raising children?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________

14. Do you experience problems with any of your family members?

Wala, mababait sila.

15. What is the role of in-laws in your life?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________
16. What are your attitudes toward pregnancy and having children? How about
contraceptives?

Pagnabubuntis ako, pinapalaglag ko.

17. Do you have any particular sexual practice that you consider unique or unusual?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
DOCUMENTATION OF THE VISIT:

Prepared By: Castillo, John Albert Matthew V.

Psy3y1-4

Clinical/Abnormal Psychology