A detailed work-up of a Mentally ill patient having Bipolar Affective Disorder (Mania)

1. PATIENT’S PROFILE
Name : Mr. P
Age : 26 years
Sex : Male
Education : 12th
Marital Status : Unmarried
Religion : Hindu
Occupational Status : Shopkeeper
Socio economic Status : Upper Middle
(Kuppuswamy S.S.S)
Domicile : Allahabad

2. SOURCE OF INFORMATION
Case Record File.
Patient himself.
Patient’s father.
Patient’s brother
Quality of information
 Reliable and Adequate

3. PERSONAL HISTORY:
Early Childhood:
• Patient was a planned child.
• Born of non-consanguineous parents.
• Full term, seizerian, with no pre/post natal complications.
• Breast feeding up-to 1 year.
• No eating problems.
• Normal developmental milestones.

4. Contd……
Middle Childhood
• Good adjustment in the school.
• Had only 1 or 2 friends (not close).
• Satisfactory social relationship.
• Prefers to be alone.

5. Childhood home environment
Patient was born in a joint family.
He is the 1st
among all siblings.
No economic hardship was present in the family.
He has got adequate love and care.

6. PLAY & GROUP INTERACTION HISTORY:
•No interest in any kind of games.
•No any close friends.
•Acquired social, community living & life skills from family elders at
optimal level.
•No history of quarreling & developing strained relationship with
community people, neighbors & friends during childhood &
adolescence.
•No history of involvement in delinquency during childhood &
adolescence.
•Interested in reading religious books (Asharam Baapu)

7. EDUCATIONAL HISTORY:
• He joined school at the age of 3 years.
• Relationship with classmates was well adjusted .
• No history of skipping classes/school refusal.
• He was poor and disinterested in studies and not involved in
extracurricular activities .
• His relation with teachers was satisfactory.
• Got fail in class 9th
.
• Studied up-to 12th
then took admission in B. Sc, failed in 1st
year
and could not continue due to illness.

8. SEXUAL HISTORY:
• Started masturbation at the age of 9-10 years.
• Acquired sexual knowledge from friends when he reached in 9th
class.
• Sexual acts with his aunt 3-4 years back with both sided
consent. (According to Patient)
• Reports of masturbatory acts accompanying his younger
brother.

9. OCCUPATIONAL HISTORY :
• Started working in his wire factory after 12th
, then got illness
and after getting well again started working at his maternal
uncle’s wire shop with share.

10. MARITAL HISTORY:
•Patient is unmarried

11. Family History

12. Family Genogram:
22 2
0
Natural
Death
ALD 68
Ear
Proble
m
Abdominal
Problem
26
5254

13. Father:
Age : 54 years of age
Education : 12th
class
Occupation : Shop owner
Personality Features:
• Calm in nature
• Religious & traditional in nature.
• Having satisfactory interpersonal relationship with
relative, neighbors & other community people.
• Satisfactory marital relationship.
• Relationship with patient is satisfactory

14. Mother:
Age : 52 years of age
Education : M.A
Occupation : House wife
Personality Features:
• Calm in nature
• Rarely aggressive, saying “I am unemployed”
• Adequate marital relationship
• Having satisfactory interpersonal relationship with
relative, neighbors.
• Concerned about patient’s illness.

15. Younger Brother:
Age- 22 years
Education – B.A
Occupation – Student
Personality Features:
• Obedient, traditionally oriented & maintains good relationship
• Caring & responsible to his duties & responsibilities to family
members
• Social & occupational adjustment- Satisfactory
• Relation with patient is good.

16. Youngest brother:
Age- 20 years of age
Education- B. Com
Occupation – Student
Personality Features:
• Calm in nature
• Caring & responsible to his duties & responsibilities to family
members
• Has good interpersonal relationship.

17. Grand Mother:
• Age- 78 years of age
• Education – Illiterate
Personality Features:
• Has good interaction with patient since childhood
• Caring in nature.
• Care towards patient’s illness.
• Rarely irritable.

18. Family History of Psychiatric Illness :
No history of mental illness in his family.
Family History of Physical Illness:
NIL

19. AVERAGE RELATIONSHIP
NEED BASED RELATIONSHIP
STRONG RELATIONSHIP
WEAK RELATIONSHIP
FATHER
PATIENT
Eco - Map
RELATIVES
BROTHERS
FRIENDS
RELIGIOUS
PLACE
NEIGHBOU
RHOOD
MOTHER

20. Family life cycle stage
• Features of Family developmental Stage: (Duvall
Classification):
• The family is in the 6th
stage of family development.
• Means family launching young adults.

21. PRESENT LIVING CONDITION
• They are living in their own pukka house.
• They have own wire Factory.
• Living style is simple.
• The house is equipped with modern electrical & electronic
gadgets .
• Adequate water & electricity supply present.
• Good sanitation maintained in house.
• Adequate space for each members of the family.

22. FAMILYFAMILY
FUNCTIONINGFUNCTIONING

23. FAMILY DYNAMICS
Family Boundaries:
System & sub-system
There are three sub-system is present in the family. (Parental,
Parent-child, Siblings)
Internal and external boundaries are clear and open.

24. Power & Authority Structure:
Leadership & decision making process:-
•Patient’s father is the nominal and functional head of the family.
•Leadership is accepted by all family members.
•The decision-making process of the family is democratic.

25. Communication Pattern:Communication Pattern:
• Patient communicates properly with his all family members.
• Channels & Noise level is normal among all family members.
• Direct communication is present.

26. Role structure and functioning:
• Roles are satisfactorily performed by all family members.
• No history of role conflict between patient and other
members of the family.

27. Cohesiveness
• Cohesiveness is present in the family.
• There is a healthy connectedness and we feeling is present
among the family members.

28. Adaptive Pattern
• Adaptive pattern is adequate.
• There is no problem in problem solving ability and coping
strategy.

29. Expressed Emotion
• Expressed emotion is high in the form of over involvement
from both parent ( father and mother) side and hostility from
patients side.

30. SOCIAL SUPPORT
•PRIMARY : Adequate
•SECONDARY : Adequate
•TERTIARY : Adequate

31. Tools Used forTools Used for
AssessmentAssessment

32. Tools Administered
1. Attitude Questionnaire
2. Social Support Questionnaire (Hindi Adaptation)
3. World Health Organization- Quality of Life (WHOQOL)
4. Family Burden Interview Schedule
5. Dysfunctional Analysis Questionnaire

33. Domains Obtained Score IMPRESSION
Critical CommentsCritical Comments 77//1010 MildMild
HostilityHostility 44//1212 AverageAverage
DissatisfactionDissatisfaction 7/127/12 MildMild
WarmthWarmth 11/1211/12 HighHigh
Over-involvementOver-involvement 12/1412/14 HighHigh
1. ATTITUDE QUESTIONNAIRE
(SETHI ET AL., 1985): ( Applied on
Father.)

34. This scale was applied on Patient:
A 18 item Social Support Questionnaire (Nehra
et al., 1996): Patient scored overall average
49/72 which is moderate level of perceived
social support.
2. Social Support Questionnaire (Applied on
Patient)

35. 3. Who-Quality of Life- BREF (Applied on
Patient)
Higher score indicates Good Quality of Life & Lower score
indicates Poor Quality of Life
Domains Obtained
Score
Maximum
score
Impression
Physical
Health
17 35 Poor QOL
Psychological 16 30 Poor QOL
Social
Relations
8 15 Poor QOL
Environment 22 40 Poor QOL

36. Area Obtained Score Max.
Score
Impression
Financial Burden 7 12 Mild Burden
Impact on Routine Family Activities 8 10 Severe Burden
Impact on Family Leisure 2 8 No Burden
Disruption of Family Interaction 1 10 No Burden
Effect on Physical Health of Others 1 4 Mild Burden
Effect on Mental Health of Others 2 4 Moderate Burden
4. Family Burden Interview Schedule
(Applied on father)
Higher Score indicates higher burden

37. Domain Obtained score Impression
Social adjustment 66% Moderate impairment
Vocational Unemployed
Personal adjustment 62% Mild impairment
Family adjustment 64% Moderate impairment
Cognitive adjustment 86% Severe impairment
5. Dysfunction Analysis Questionnaire
(Pershad et al., 1985) Applied on Patient
Cut off score is 40% , means no impairment
40- 60 – mild impairment
60-80 – moderate levels impairment
80 – 100 – severe levels of impairment

38. PSYCHOSOCIAL FORMULATION:
Index patient Mr. p, 26 year old, male, educated up to 12, from
urban background of Allahabad, came to IMHH for seeking
treatment for his psychological problems.
At the time of consultation patient was accompanied by his father
and brother
From Consanguineous parentage and from nuclear family.
Patient is the first one among three siblings.
He had few friends in schooling and colleges and right now he has
one and two friends for the religious purpose.
Patient has high risk for social isolation.

39. Father being the nominal and functional head of the family is
over concerned of patients illness.
Value & belief system of the family is religious & traditional in
nature.
Social Support System in the family at primary ,secondary and
tertiary level is adequate
Social connectedness of the family is optimal.
Over involvement and over protective by mother and father
both side.
Family Burden Interview Schedule reveal moderate level of
burden in the area of mental health of others and severe level of
impact on family routine activity.

40. WHO-QOL shows poor quality of life in all the domains like
physical health, psychological, social and environmental.
Dysfunctional analysis shows severe level of impairment in
cognitive adjustment and moderate level of family
adjustment.
Attitude Questionnaire shows positive expressed emotions
are high like over involvement and warmth.

41. Psychosocial
DiagnosisPSYCHO–SOCIAL
DIAGNOSIS

42. Psychosocial Diagnosis (ICD 10- Axis-III)
Z62.1- Problems related to upbringing
(Parental Overprotection)
Z60 - Problems related to social environment.

43. MANAGEMENT PLAN
Immediate
• To build rapport with the patient and to monitor the patient.
Short Term Goals
• To educate the patient and family members regarding his illness and
about role of the drugs in the treatment of his illness
• To develop insight about illness.
• To reduce high expressed emotions.
Long Term Goals.
• To improve quality of life.
• Regular follow up.

44. MANAGEMENT PACKAGE
Short Term
• Psycho education.
• Life skill education.
• Insight oriented psychotherapy
• Supportive counseling.
• Family Counseling
Long Term
• Regular follow up