PSYCHOLOGY REPORT Patients Name: Sex: Age: Pav/Ward: Birthday: Birthplace: Civil Status: Educational Attainment: KUE, JOANNE

C. F 23 Pav.2-OPS May 26, 1983 Sorsogon Single 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 Sachs Sentence Completion Test Minnesota Multiphasic Personality Inventory Test-I Thematic Apperception Test Behavioral Observation Examinee is a young adult female who stands 55 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 fathers 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 subjects 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 fathers 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 Performance Full

Scale IQ-87 Scale IQ-88 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 faade 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 fathers 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, Jehovahs 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 patients 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 fathers 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 brothers 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 patients 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 patients 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 patients 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 fathers 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 fathers arrival home to find a reprieve. No nightmares, phobias, cruelty to animals reported. LATE CHILDHOOD The patients 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 2890 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 dates 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 brothers 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 fathers death. She enjoyed the social exposure she experienced. No sexual intimacy ensued and the relationship ended and the relationship ended due to the boyfriends 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 Jehovahs 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 patients 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 Jehovahs 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, Im 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 fathers 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 onon the move palagi. She added lahat sasabihin, lahat gagawin in a matter of hours, tapossobrang depressed na ako. Sa kwarto lng ako, she said people saw her as masayahin, I dont 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 nondisruptive 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 selfregulation; (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