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Gangguan Afektif BipolarSCENARIOMrs. Sorrowati was a forty five years old teacher who lived in the rural area. About three months ago, she started a fight with her husband like they always did before. A couple of days after the fight, she started to look gloomy. At times, she would be found in her room weeping. She often woke up late in the morning, and more often sleep lately after usual bedtime. She usually lay still while observing the ceiling during her not sleeping period. She withdrew her hobby of singing and dancing at the local wedding party. Instead, she locked herself in her room during the occurrence of the party. She refused to communicate the problem of her concern. In fact, she was very quite at any time during the day. At work, she always gave her students an assignment instead of teaching them. About two months ago, it was noticeable that her weight had decreased. During a silent observation, her mother caught her dispose her dishes which she brought to her room. When asked about this, she stated that she no longer had the appetite and refused to eat further. She failed to fulfill her job to cook for the household. Her mother then took her role in the kitchen. She also failed to attend to her job location, and was given a warning note from her superior. About one month ago, she looked more anxious. For every job she failed to do, she blamed herself for being guilty. At morning, she would complain her fatigue and stated that she wont make anything out of the day. At noon, she would complain her inability to do things straight. And at evening, she would complain her failure to anything useful that day. Once, her mother caught her trying to swallow a large quantity of headache pills. After a family discussion, it was agreed that she would be taken to see an herbalist, but after seeing no progression towards remission, she was brought to the Psychiatric Clinic by her mother and her husband. A psychiatric examination was then performed by the attending psychiatrist. Premorbid Historyy y

Birth: spontaneous birth delivery, lead by a doctor Childhood, adolescence & adult: she was generally considered a nice, cheerful, and communicable person

Previous Mental Disorder and Organobiologic Development Historyy

About a year ago, she exhibited an odd behavior. Back then, she would talk to everybody about her intimate activity and laughed out loud at each story. She also spent most of her wage on charity. She almost never rested without feeling exhausted. This condition was accounted for at least a month, after which she returned normal gradually. There was no organobiologic developmental history attributable to present illness.

y

By: BeBi (Bebek&Qolbi)

Page 1

Family Hitoryy

She was the third of seven siblings. Her parents treat their children as fair as possible, and their children were generally happy with their parents. No mental disorder was noted in her family. Her relationship with her siblings was good, although at sometimes she would fight for her parents affection.

Educational Historyy

She was quite a reasonable student during her school age. She collected her friends who were lesser academic performer than her. She would then teacah them, and in turn receive admiration from them. She graduate from SMA and started her college at FKIP at her own decision and finished her study after five years.

y

Occupational historyy

Shortly after her graduation, she applied to former SMA and was accepted as a honorary teacher for three years. At fourth year, she followed the CPNS examination and was granted the position of permanent teacher. She taught with her heart and never complained about her work. But her history was marred by several scandals involving Mrs. Sorrowati and her student in some kind love affair.

Marital historyy

She was married to her husband during her study at college. She admitted that the marriage was not based upon love and devotion, and it was only an accident. Her husband was only a graduate of SD and never had permanent job (rather opposite from her ideal husband figure), and she regardes as a Mister Know-It-All. Her husband was regarded as a supicious person burnt in jealously. Most of their daily life, they fought each other either orally and sometimes physically. Before marrying her husband, Mrs. Sorrowati had numerous, but once at a time boyfriend. The family economi wa supported by Mrs. Sorrowati. They lived a rather deficient life. At her adolescense, Mrs. Sorrowati was known to be active in most committee of any event, especially celebrating The Independence Day. She was also known to be fond of singging at many parties and as a generous girl who lend her clothing to other in charity show, although she herself was not in an excess condition She had many friends, most of them were subject for her boastings. She was regarded as a commoner in religion.

y

Economical statusy

Social relationship & activityy

y y

By: BeBi (Bebek&Qolbi)

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The following information was recorded during autoanamnesis and simultaneous observation. The voice of Mrs. Sorrowati was generally slow and small. Examiner Mrs. Sorrowati Good Morning maam, how may I help Good morning (glanced the eyes briefly you? (looking the eyes; offering to shake then faced turned down;accepted the hand) hands) Im physiciatrist here, what is your name Sorrowati maam? How do you feel today? Why are you crying? Are you sure its that much? But Godmercy is above all May I know what are they? I feel very bad, doc (suddenly she cried) Im sinful, so much sin had I commit Yes, and Im very sure that I may not be forgiven I dont know I ran away from home, talk to everyone about the evil of my husbands and I enjoyed it so much Is it right to do so? Do you love your husband? Why? (talking to husband) is it right sir? How many times it happened? Of course not. Why should I felt guilty if its right No way He hit my head (husband answering) yes, I lost control. Twice, the first was when she turned mad a year ago. (talking to miss sorowati) have you any .. hallucination mam? source, or something like a shadow only you can see? Okay I think its enough for our initial Thank you interview. I expect to se you again next week. The following interview Good morning miss sororwati, how are you Fine, actually I feel good today. feeling today? Sorry? I mean, voices of which you dont see the No

By: BeBi (Bebek&Qolbi)

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Could you explain it?

I felt very easy. Now that Ive lost the burden of my shoulder.

If im not mistaken, youve tried to swallow I was considering suicide. I cant hold on a large amount of pill that day. What do with the burden you intend to do? What made you cancel the act? How are you doing now? What about your job? So youre still feeling sinful? No do you feel unforgivable? What are your plans afterwards? And then? The physical examination of Mrs. Sorrowatiy

My mother caught me before I commence it. But I also think about my children I can do many things again. I can cook again. I dont attend school right now. I still think im a disgrace A little, but I think ill recover in time No, I realize my husbands fault is his to consider, not mine I want to divorce my husband I dont know next

Vital Sign : Blood Pressure 110/60 mmHg, Pulse Rate 62x/min, Respiration rate 15x/min, Axial temperature 36,90 C. Physical examination : Normal Neurological examination : normal

y y

The psychiatrist then concluded the examination by identifying psychopathologies for main condition, mood/affective state, emotional life, thought process, perception & sensation, intelligence function, and instinctual & behavioural drive based on comprehensive alloanamnesis, autoanamnesis, and observation to make the multiaxial diagnoses and therapeutical planning.

TERM CLARIFICATION1. Fight 2. Gloomy 3. Anxious : Bertengkar : Murung : Ketegangan, rasa tidak aman dan kekawatiran yang timbul karna dirasakan akan tejadi sesuatu yang tidak menyenangkan tetapi sumbernya tidak diketahui 4. Rural area 5. Sleep lately : Daerah pinggir kota : Tidur larut malam

By: BeBi (Bebek&Qolbi)

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6. Appetite 7. Fatigue 8. Blamed 9. Guilty 10. Headache pills 11. Psychiatric clinic 12. Herbalist 13. Remission

: Nafsu makan : Kelelahan secara mental atau fisik : Menyalakan diri sendiri, karna merasa tindakan nya salah : Perasaan bersalah pada diri sendiri : Obat sakit kepala : Fasilitas layanan kesehatan khusus kejiwaan : Ahli tanaman obat : pengurangan atau meredanya gejala suatu penyakit, lama waktu terjadinya : Memprihakan prilaku aneh

14. Exhibited an add behavior

PROBLEM IDENTIFICTION1. Mrs. Sorrowaty 45 yo old teacher who lived in the rural area. About 3 months ago : she started a fight with her husband like they always did before. A couple days after the fight, she started to look gloomy. She would be found in her room weeping. She often wake up late in the morning and more ofte sleep lately after her usual bed time. She usually lay still while observing the ceiling during her not sleeping period. She refused to communicate the problem of her concern. She was very quiet at anytime during the day. At work, she always gave her student an assignment instead of teaching them. Her weight had decreased. She no longer had the appetite and refused to eat further. She failed to fulfill her job to cook for the house hold. She also failed to attend to her job location and was given a warning note from her superior. 3. About 1 month ago :

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2. About 2 months ago :

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She looked more anxious She blamed her self for being guilty because of every job she failed to do. At morning, she would complain her fatigue and stated that she wont make anything out of the day.

By: BeBi (Bebek&Qolbi)

Page 5

-

At noon, she woukd complain her inabiity to do thigs right. At evening, she would vomplsin her failure to do anything useful that day. Her mother trying to swallow a large quantity of headache pills. About a year ago, she exhibited an odd behaviour :

4. Previous Mental Disorder and Organobiologic Develompment History.

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She would talk to everybody about her intimate activity and laughed out loud at each story. She also spent her most wage on charity. She almost never rested without feeling exhausted. This condition was accounted for at least a month, after which she returned normal gradually.

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5. Occupation history Shes accepted as an honorary teacher for 3 years. At fourth year, she was granted the position of permanent teacher. But her history was mrred by several scandals involving mrs. Sorowati and her student in some kind f love affair. 6. Marital history : She admitted that the marrieage was not bsed upon love and devotion, and it was only accident. Her husband was only graduate of SD and never had any permanent job (rather opposite from her ideal husband figure), and she regarded her as Mister knowit-all. Her husband was regarded as a suspicious person burnt in jealously. Most of daily life, they fought each other either orally and sometimes physically. Before marrying her hsband, mrs. Sorrowaty had numerous, but once at a time, boyfriend. 7. Economical status : The family economy was supported by mrs. Sorrowaty. They lived a rather deficient life. 8. Folowing information was recorded during anamnesis : 1. The voice was generally slow n small 2. Minimal eye contact 3. Affect hipotemic 4. Emosi labil and uncontrol 5. Her husband hit her at her head

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By: BeBi (Bebek&Qolbi)

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PROBLEM ANALYSIS1. Bagaimana kondisi Mrs. Sorrowati :

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3 bulan yang lalu 2 bulan yang lalu 1 bulan yang lalu

2. Bagaimana perkembangan kepribadian premorbid Mrs.Sorrowati ? 3. Bagaimana riwayat gangguan mental sebelumnya dengan kondisi diatas ? 4. Bagaimana hubungan riwayat keluarga dengan kondisinya sekarang? 5. Bagaimana hubungan pergaulan dia dengan murid-muridnya dengan kondisinya sekarang? 6. Bagaimana riwayat perkawinan dan kondisi rumah tangganya ? 7. Bagaimana hubungan status ekonomi Mrs.Sorrowati dengan keadaannya ? 8. Bagaimana interpretasi pemeriksaan fisiknya? 9. Bagaimana interpretasi auto anamnesis berdasarkan psikopatologi ? 10. How to dignose ? 11. DD ? 12. WD? 13. Management? 14. Prognosis ? 15. Komplikasi? 16. KDU ?

HYPOTHESISMrs. Sorowati, 45 tahun, seorang guru menderita Gangguan afektif bipolar episode kini depresi berat tanpa gejala psikotik (F31.4).

By: BeBi (Bebek&Qolbi)

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Kerangka konsep

I. KERANGKA KONSEPDari riwayat pendidikan, dia senang berteman dengan teman yang akademiknya dibawah dia sehingga dia bisa mengajari temannya dan mendapat pujian Dari riwayat pekerjaan, pernah terlibat dalam skandal percintaan dengan muridnya

F60.4 kepribadian histrionik Mrs. Sorrowati 45 thn, seorang guru

1. Menikah karena kecelakan tidak didasari perasaan cinta atau sayang 2. Mrs. Sorrowati menikah saat masih dibangku kuliah 3. Suaminya hanya tamatan SD, tidak punya pekerjaan tetap, dan pencemburu

1.

2.

Ekonomi keluarga ditanggung oleh Mrs. Sorrowati Mereka hidup cukup kekurangan.

Mrs. Sorrowati memiliki skandal percintaan dengan muridnya yang mencoreng nama baiknya

Selalu bertengkar dengan suaminya. Kadang-kadang suaminya memukulnya (kontak fisik)

Riwayat gangguan mental sebelumnya Sekitar satu tahun lalu, dia menunjukan perilaku aneh. Dia menceritakan kepada setiap orang tentang aktivitas intimnya dan tertawa terbahak-bahak di setiap cerita. Dia juga menghabiskan sebagian besar gajinya untuk amal. Dia hampir tidak pernah istirahat tanpa merasa kelelahan. Kondisi ini terjadi setidak-tidaknya selama 1 bulan

3

1 Berangsur normal

bulan lalu: - Bertengkar lagi dg suaminya Setelah itu Mrs. Sorrowati mjd murung, kdg Nafsu makan berkurang Tidak masuk kerja bulan lalu: - Gelisah/cemas (depresi) Mudah lelah Konsentrasi & perhatian berkurang(Setiap pekerjaannya selalu gagal dia kerjakan) Merasa bersalah dan tidak berguna Berusaha untuk bunuh diri(menelan pil sakit kepala dlm jumlah besar )

Gangguan afektif bipolar, episode kini depresi berat tanpa gejala psikotik (F31.4)

By: BeBi (Bebek&Qolbi)

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SYNTHESIS 1. Interpretasi AutoanamnesisExaminer Mrs. Sorrowati Interpretasi Good Morning maam, how Good morning (glanced the Kontak mata minimal may I help you? (looking the eyes briefly then faced turned Keadaan fisik baik eyes; offering to shake hands) your name maam? How do you feel today? I feel very bad, doc (suddenly she cried) Mood : hypothimic ( abnormal tonus emosi) Mood appropriate affect (dlm keadaan murung/depressed/suram & sesuai dgn keadaan yang dialaminya sekarang menjawab pertanyaan sambil menangis) Why are you crying? Are you sure its that much? But Godmercy is above all May I know what are they? Im sinful, so much sin had I commit Yes, and Im very sure that I may not be forgiven I dont know I ran away from home, talk to everyone about the evil of my husbands and I enjoyed it so much Is it right to do so? Do you love your husband? Why? sir? Of course not. Why should I felt guilty if its right No way He hit my head lost control. Good judgement, Pernyataan yang benar (merasa kalo apa yang dilakukannya itu salah/tidaklah benar) down;accepted the hand) Verbal : baik Pasien cooperative Im physiciatrist here, what is Sorrowati

Merasa bersalah (persistent idea of sin)

Hubungannya suami tidak baik

dengan

(talking to husband) is it right (husband answering) yes, I

By: BeBi (Bebek&Qolbi)

Page 9

How many times it happened? Twice, the first was when she turned mad a year ago. (talking to miss sorowati) .. have you any hallucination Sorry? mam? I mean, voices of which you No dont see the source, you can see? Okay I think its enough for Thank you our initial interview. I expect to se you again next week. The following interview Good sororwati, morning how are you today. I felt very easy. Now that Ive lost the burden of my shoulder. If im not mistaken, youve I was considering suicide. I Idea of suicide in the past tried to swallow a large cant hold on with the burden amount of pill that day. What do you intend to do? What made you cancel the My mother caught me before I act? How are you doing now? What about your job? commence it. But I also think about my children I can do many things again. I Fungsi can cook again. now. I still think im a disgrace So youre still feeling sinful? No do you feel unforgivable? pada pekerjaan masih kurang dibanding baik sebelumnya. A little, but I think ill recover Traces idea of sin (masih in time ada perasaan berdosa, tapi No, I realize my husbands kondisi sudah lebih baik dibanding Interpretasi miss Fine, actually I feel good Mood : euthymic or something like a shadow only Tidak ada halusinasi

feeling today? Could you explain it?

I dont attend school right biasanya, tapi sudah lebih

By: BeBi (Bebek&Qolbi)

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fault is his to consider, not mine What are your plans I want to divorce my husband I dont know next

dibanding sebelumnya) Mampu membuat rencana yang akan dilakukan dalam jangka waktu dekat

afterwards? And then?

Kesimpulan hasil pemeriksaan psychiatric (psycopatologic, autoanamnesis, dan observasi)y

Main condition Keadaan affective Suasana Hati Kehidupan emosional Pemikiran

: verbal adekuat, dan ada kontak fisik, kontak mata minimal, menunjukan sikap kooperatif : hypothymic mood, appropriate affect (sikap yang tepat) : kesedihan mendominasi, tertekan : labile, mudah mengekpresikan apa yang dirasakan : a. Arus pikiran Normal ( pikiran berjalan dari suatu ide awal ide tujuan), no flight of idea,menyimpang dll. b. Pemilikan pikiran Normal ( individu menghayati pikiran yang dikeluarkan sebagai miliknya), pikiran obsesi (-), alienasi (-) c. Isi pikiran adanya perasaan berdosa dan bersalah d. Bentuk pikiran Normal pasien mampu berpikir rasional / logis

y y y y

kesimpulan: *Persistent idea of sin maknanya : gagasan tentang rasa bersalah. Dan merupakan ciri dari adanya gejala depresi *Suicide ideation maknanya: merasa beban yang dialaminya terlalu berat, merasa sangat bersalah dan tidak bisa melakukan apapun. Dan pada akhirnya berpikir tentang kematian karena merasa tidak ada gunanya lagi hidup. *Pessimistic vision *Hostilityy y

Persepsi Pengertian diri

: pemikiran dan merasa berdosa, penyesalan yang dalam : gagal melakukan tindakan yang penting, sedikit pengertian pada diri sendiri, mempengaruhi penilaian orang terhadap dirinya

By: BeBi (Bebek&Qolbi)

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y y

Sensasi Fungsi intelegensi

: normal, tidak ada halusinasi maupun delusi : normal a. Kesadaran = compos mentis b.Orientasi = baik c.Daya ingat = baik /normal d.Konsenterasi dan perhatian = baik

y

Instinctual dan kondisi

: hipobulia (kehilangan dorongan berkehendak) perbuatan ingin mengakhiri hidup (suicide act), kehilangan berat badan, sulit tidur

y y

Anxiety Tes kemampuan realita

: tidak ada gejala cemas yang terlihat : perasaan, pemikiran, persepsi, tingkah laku mengalami gangguan

2. Interpretasi Pemeriksaan Fisika.Vital sign a. Tekanan darah 110/60 b. Tekanan nadi 62x/mnt c. Respiration rate 15x/mnt d. Axial temperatur 36,9 c b.Pemeriksaan fisik c.Pemeriksaan neurologis = normal = normal = normal rendah = normal = normal rendah = normal

3. Interpretasi Pemeriksaan Alloanamnesis a. Premorbid HistoryBirth Childhood : spontaneous birth : nice, cheerfull and communicable person

Dapat di simpulkan bahwah tidak ada gangguan pada riwayat kelahiran mrs Sorrowati.

b. Previous Mental Disorder and Organobiologic Developmental Disordery

Satu tahun lalu, Perilaku aneh, sering menceritakan aktivitas pribadinya, tertawa keras di tiap cerita gangguan kepribadian manic (1) menunjukkan bahwa Menyumbangkan sebagian besar pendapatannya pada acara amal

y

Ny. Sorrowati ingin dipuji oleh banyak orang gangguan kepribadian manic (2)

By: BeBi (Bebek&Qolbi)

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y Ia hampir tidak pernah istirahat tanpa merasa lelah menunjukan bahwa telah erjadi episode

manik pada mrs sorrowati (3)

(1), (2), dan (3) : Ketiga perilaku di atas menunjukkan bahwa pasien mengalami episode afektif manic, yaitu mood yang meninggi, ditunjukkan dengan sikap meluap-luap, gagasan yang meloncat-loncat (fight of ideas), penurunan kebutuhan tidur, peninggian harga diri, dan gagasan kebesaran.y

Kondisi pasien ini dilaporkan sedikitnya selama 1 bulan, setelah dia berangsur angsur kembali normal.

Pada gangguan afektif bipolar, yang khas terdapat penyembuhan yang sempurna antar episode dan episode manic biasanya mulai tiba-tiba dan berlangsung antara 2 minggu sampai 4-5 bulan.

c. Family HistoryTidak terdapat masalah yang berati dalam riwayat keluarga mrs sorrowati. Hanya saja, mrs Sorrowati merasa kurang mendapat perhatian dari orangtua.

d. Education History and Social Relationshipy

Mrs Sorrowati mengumpulkan teman-temannya yang kemampuan akademik diabawahnya dan mengajarkan mereka, lalu mendapatkan sanjungan dari teman -teman nya hal ini menunjukan bahwa Mrs Sorrowati memiliki kepribadian histrionik yaitu ia Terus-menerus mencari kepuasan (excitement), apresiasi oleh orang lain dan aktivitas di mana pasien menjadi pusat perhatian.

e. Ocupational Historyy

Ny. Sorrowati terlibat skandal asmara dengan siswanya

menunjukkan gangguan

kepribadian histrionik (menunjukan perilaku mencari perhatian yang tinggi)y

Pada orang-orang dengan gangguan kepribadian histrionik, impuls seksual mereka mungkin dilakukan untuk menentramkan diri mereka bahwa mereka menarik bagi jenis kelamin lain.

f.

Social relationship & activityPribadi Ny. Sorrowati yang cenderung untuk berbagi meskipun ia sendiri dalam kondisi yang tidak memungkinkan, kemudian selalu aktif dalam berbagai cara, sering membual atau menyombongkan diri menunjukkan kepribadian pasien cenderung

histrionic .

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y

Dari hasil anamnesis riwayat pekerjaan, pendidikan, dan sosial tercermin bahwa nyonya Sorrowati Memiliki gangguan kepribadian histrionic.

Dapat dijelaskan bahwa: F60.4 Gangguan kepribadian HistrionikGangguan kepribadian yang ditandai oleh: a) Ekspresi emosi yang didramatisasikan sendiri, teaterikalitas, dan dibesar-besarkan; b) Bersifat sugestif,mudah dipengaruhi oleh orang lain atau keadaan; c) Afek datar dan labil; d) Terus-menerus mencari kepuasan (excitement), apresiasi oleh orang lain dan aktivitas di mana pasien menjadi pusat perhatian; e) Kegairahan yang tidak pantas dalam penampilan atau perilaku; Gambaran penyerta mungkin mencakup egosentrisitas, pemuasan diri, terus -menerus mengharapkan apresiasi, perasaan mudah tersinggung dan perilaku manipulatif yang menetap untuk mencapai kepentingan pribadi. f) Terlalu mementingkan daya tarik fisik.

g. Marital History

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Kehidupan rumah tangga tidak harmonis. Dari scenario di dapatkan bahwa Mrs. Sorrowati menikah Karena kecelakaan/kehamilan di luar nikah status suami lebih rendah dibanding istri, ekonomi RT kekurangan, sifat suami cemburuan. tindak kekerasan dalam rumah tangga (KDRT).

Keadaan ini semua dapat menimbulkan stressor psikis bagi si pasien. Sehingga lamakelamaan menyebabkan episode depresif.h. Economical Historyy

Mrs Sorrowati adalah tulang punggung keluarga nya dan suaminya tidak memiliki pekerjaan tetap serta hanya lulus dari sekolah dasar. hal ini sangat berpengaruh pada kondisi psikis mrs Sorrowati yang berdampak pada depresi berat yang dialaminya. Peristiwa stressful

merupakan prediktor terkuat untuk kejadian episode depresi.

By: BeBi (Bebek&Qolbi)

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Faktor lingkungan dan psikososial (riwayat keluarga) Mencari perhatian ortu,merasa kurang dieperhatikan

Faktor genetik

Faktor biologis (neurotransmitter,hor mon,neuroanatomi, imun)

Faktor psikososial (stress,factor kepribadian,psiko dinamika) Kehidupan pernikahan yg tidak bahagia dan tidak sesuai harapan,dipukul suami (Stresor)

Gangguan afektif bipolar

Kompensasi maladaptif Mempertahankan mekanisme defens imatur yang khas

Episode mania (kejadian 1 tahun lalu)

Gang.kepribadian histrionik

Episode kini depresif berat tanpa gejala psikotik (dimulai dari 3 bln lalu sampai

Mencari penghargaan dari orang lain,ingin selalu jadi pusat perhatian

Afek dangkal dan labil Menikah karena kecelakaan , figure suami tidak sesuai harapan, pencari nafkah Mrs.Sorrowati, rather deficient life

Mengumpulkan teman yg performa akademiknya