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1 bipolar disorder 8 Captain of the Ship: Bipolar Disorder The following case study details the treatment approach for a 35-year-old Caucasian male who presented to the clinic for help with his mood disorder. The assessment and intake supported the diagnosis of bipolar disorder, subtype II. The following analysis presents the details related to both pharmacology and psychotherapy, as well as information related to medical management, community support resources, and appropriate follow-up. Chief Complaint The client came to the clinic reporting that he “could no longer deal with his up-and-down mood swings and that he was at the end of his rope.†History of Presenting Problem This client stated that he has had mood swings for as long as he could remember, and that right now he was in the “up†phase of this alternating mood pendulum.
From an inspection of the genogram that the client provided, there was a noticeable inheritance pattern of the bipolar. Notably, this client had evidence of bipolar on both maternal and paternal sides of his genogram. Research has shown that bipolar has a high heritability rate. Kern (2014) reported on the concordance rates of twins with bipolar, stating the rate was from 60-80%. In other studies, the heritability of bipolar is demonstrated albeit at lower rates (Maier et al. (2005).
The DSM-V characterizes bipolar II disorder as one in which individuals experience a period of at least 4 days of hypomanic symptoms; once this criterion is met, the person fits the diagnosis of bipolar II regardless of the duration of future hypomanic episodes (APA, 2013). Additional symptoms to support this diagnosis were the client’s admission that he was taking on several projects and tasks at work simultaneously; sleeping little; experiencing racing thoughts; and feeling invincible. The intake showed the client’s extremely fast talking, switching subjects haphazardly, and admission of both depressive and hypomanic episodes, all of which point to a diagnosis of bipolar II (296.89 F31.81) (APA, 2013).
Current Medications This client denied taking any medications, either over the counter or from a doctor. Although he claimed he was in good health, he did report that he frequently got headaches but not of migraine proportions. He described them as more of an annoyance than a health problem. He gained relief from either Motrin or Tylenol during these headache episodes. He denied taking any vitamins or herbs or any other OTC substances.
Relevant History The client reported that his mood swings began when he was in his early 20s. As he witnessed other family members suffering from these mood swings, he came to believe they were normal. The client appeared to be in good health, was not overweight, and appeared to take good care of himself. He was dressed well and was oriented x4. He stated that he earned a good living working as a financial consultant, enjoyed his work, but could not deal with the revolving mood swings anymore.
His purpose for coming to the clinic was get help for this apparent mood disorder. Diagnostic Impression As stated, the client’s symptomatology and relevant history align with a diagnosis of bipolar disorder, subtype II. Running along a continuum from mild to severe, this disorder is saliently circumscribed by the major depressive phase alternating with the hypomanic phase (Antokhin et al., 2010; APA, 2013). The DSM-V clearly states that the bipolar II diagnosis is confirmed by individuals’ experience with at least one episode of major depression and at least one hypomanic episode (APA, 2013; Samalin et al., 2016). Because the client has never experienced a full-blown mania, so typical of the bipolar I subtype, the diagnosis is best supported by the criteria of the bipolar II subtype.
Psychopharmacology and End Points Both subtypes of bipolar can be extremely debilitating to individuals who suffer from these illnesses. For one, this client reported regular sleep disturbances and an omnivorous appetite for increased responsibilities at work, the result of which could be extreme overwhelm. Sadock et al. (2014) described such overwhelm, stating that bipolar individuals often experienced extreme emotional distress because of such unrelenting task assumption. The typical treatment for bipolar patients and one directed at mood stabilization is lithium therapy (Stahl, 2013). The recommended regimen based on all the information for this case would be 600mg of a lithium salt TID.
Ward (2017) reported on the efficacy of this treatment to target the up-and-down nature of the disorder. During lithium therapy, clients must have their blood monitored regularly to ensure that the target of 1-1.5mEq/L blood serum levels is established (Sadock et al., 2014). Supplemental pharmacology might include the drugs venlafaxine and olanzapine, the first an antidepressant and the second an antipsychotic (Stahl, 2013). These meds would help with any psychotic episodes that the client might experience (Sadock et al., 2014). To avoid overprescribing of psychotropics, no adjutant therapy would commence until the results of lithium therapy have been established.
The therapeutic endpoint would be improvement in the client’s mood swings over the ensuing weeks after initiation of pharmacology. Psychotherapy and End Points The gold standard of psychotherapy is cognitive behavioral therapy (CBT) and will be recommended on a weekly basis. The literature is replete with research supporting the efficacy of CBT in bipolar cases (Jones et al., 2012; Sadock et al., 2014). Gabbard (2014) reported that bipolar patients who attended regular CBT therapy enjoyed welcome relief from the nefarious symptoms of the illness. But as with other mental health disorders, bipolar is best treated with a multimodal approach.
Antokhin et al. (2010) discussed the benefits of sociotherapy to complement modalities like CBT and other group behavioral therapies. The endpoint of psychotherapy would be to restore normal functioning to the client, as much as is realistically possible, and see him begin to be less hampered by the disorder, especially insofar as his sleep disturbance and feelings of invincibility. Medical Management and Follow-Up Importantly, lithium therapy can be dangerous if blood levels rise to 2.5mEq/L (Sadock et al., 2014). For this reason, the client will be sent for regular blood draws to ensure levels remain within the safe zone. Moreover, the client will be enjoined to see his regular doctor for routine vaccinations and other preventive routine diagnostic tests.
The client will be educated on the important side effects of pharmacology. Notably, lithium can produce side effects of diarrhea, muscle fatigue, and shaky gait (Stahl, 2013). The client will be advised to notify his doctor immediately of any of these problems and to report to the nearest hospital for emergency care. Support Resources The National Alliance on Mental Illness (NAMI) offers a wide range of social support services through its website and national hotline. These services encompass everything from a suicide hotline to help finding a mental health specialist to books and other printed materials on bipolar (NAMI, 2018).
Another online resource is the Depression and Bipolar Support Alliance (DBSA), which offers abundant information on bipolar and related mood disorders (DBSA, 2020). The FAIR START program helps persons with bipolar to find expert clinical research on the disorder (FAIRSTART, 2019). This program is run by Stanford Medical School and offers help for bipolar individuals to get evaluated properly and find appropriate treatment. References American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
APA. Antokhin, E., Bardyurkina, V., Budza, V., Kryukova, E., & Baldina, O. (2010). Bipolar depression of the II type: Psychopathology, therapy. European Psychiatry , 25 . Depression and Bipolar Support Alliance (DBSA). (2020).
FAIR START. (2019). From affective illness to recovery: Student access to rapid treatment (FAIR START). Stanford Medicine . Gabbard, G. O. (2014).
Gabbard’s treatment of psychiatric disorders (5th ed.). American Psychiatric Publications. Jones, S., Mulligan, L. D., Law, H., Dunn, G., Welford, M., Smith, G., & Morrison, A. P. (2012).
A randomized controlled trial of recovery focused CBT for individuals with early bipolar disorder. BMC Psychiatry , 12 : 204. Kerner, B. (2014). Genetics of bipolar disorder. Applied Clinical Genetics, 7 : 33-42.
Maier, W., Hà¶fgen, B., Zobel, A., & Rietschel, M. (2005). Genetic models of schizophrenia and bipolar disorder: overlapping inheritance or discrete genotypes? European Archives of Psychiatry and Clinical Neuroscience , 255 (3), 159–166. National Alliance on Mental Illness (NAMI). (2018). Retrieved June 30, 2020 from Sadock, B.
J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Wolters Kluwer. Samalin, L., de Chazeron, I., Vieta, E., Bellivier, F., & Llorca, P. (2016).
Residual symptoms and specific functional impairments in euthymic patients with bipolar disorder. Bipolar Disorders, 18 (2), 164–173. Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.).
Cambridge University Press. Ward, I. (2017). Pharmacologic options for bipolar disorder. Clinical Advisor, 20 (3), 17–25.
Paper for above instructions
Bipolar Disorder: A Case Study of Treatment ApproachesIntroduction
Bipolar disorder, characterized by mood swings ranging from depressive lows to hypomanic highs, is a complex mental health condition requiring comprehensive management strategies. This case study follows a 35-year-old Caucasian male diagnosed with bipolar disorder subtype II. The analysis focuses on the pharmacological and psychotherapeutic interventions, community support, and necessary follow-up care.
Chief Complaint
The patient reported to the clinic with significant distress due to persistent mood swings. He expressed frustration, stating he “could no longer deal with his up-and-down mood swings.” The urgency and desperation in his voice indicated the need for effective intervention.
History of Presenting Problem
The patient’s mood fluctuations began in his early twenties, paralleling a family history of similar disorders, as evidenced by his genogram. Recent research supports a high heritability rate for bipolar disorder, particularly among first-degree relatives (Kern, 2014). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), identifies bipolar II disorder by the presence of at least one hypomanic episode and recurrent major depressive episodes (APA, 2013). The patient articulated increased responsibility at work, sleep disturbances, and racing thoughts—hallmarks of the hypomanic phase.
Current Medications
The patient reported not currently taking any medications, essential to note given the history of headache complaints. Understanding his medication history is crucial for developing a treatment plan that minimizes risks and side effects (Sadock et al., 2014).
Relevant History
Despite a successful career as a financial consultant, the patient's mood states impacted his performance and well-being. He appeared physically well-maintained, suggesting an awareness of self-care, yet remained troubled by his psychological condition. This dichotomy is common in bipolar individuals, who often present well superficially while suffering internally (Antokhin et al., 2010).
Diagnostic Impression
Upon careful examination, the patient's symptomology aligns with bipolar disorder subtype II (APA, 2013). His experience of recurrent depressive episodes intermixed with hypomanic phases substantiates this diagnosis. The absence of a full manic episode clears the pathway for classifying his condition as bipolar II, rather than bipolar I (Sadock et al., 2014).
Psychopharmacology and Treatment End Points
Bipolar disorder management often necessitates pharmacological intervention alongside psychosocial strategies. Lithium carbonate remains the gold standard for mood stabilization (Stahl, 2013). For this patient, a recommended starting dose would be 600 mg TID, with regular monitoring to ensure therapeutic blood levels between 1-1.5 mEq/L (Ward, 2017). Given the patient’s symptom structure, adjunct medication could include venlafaxine and olanzapine for potential depressive phases and mood stabilization (Sadock et al., 2014).
Psychotherapy and Treatment End Points
Cognitive Behavioral Therapy (CBT) is the leading psychotherapy modality for patients with bipolar disorder (Jones et al., 2012). The goal of therapy is to enhance mood stability, improve coping strategies, and establish a supportive routine. Regular attendance to therapy sessions will be vital for monitoring the patient’s psychological health and adherence to medication management.
Medical Management and Follow-Up
Given the potential risks associated with lithium therapy, including toxic effects at elevated blood levels, the patient will need frequent blood tests. The healthcare team should provide thorough education about side effects, including the risk of gastrointestinal disturbances and increased thirst (Sadock et al., 2014). It is imperative that the patient does not neglect routine medical checks for comorbid conditions that often accompany mood disorders.
Support Resources
Engagement with community resources can foster a supportive network for the patient. Organizations like NAMI and DBSA offer valuable educational materials, support groups, and helplines that can enhance his understanding of bipolar disorder (NAMI, 2018; DBSA, 2020). Programs like FAIR START can help connect him with research and treatment modalities at leading institutions (FAIR START, 2019).
Conclusion
The management of bipolar disorder, particularly subtype II, requires a careful balance of pharmacologic and psychotherapeutic strategies. This case study highlights the importance of a comprehensive approach tailored to the individual’s unique symptoms and life circumstances. Regular follow-up, ongoing education, and community support will all contribute to improved outcomes for patients like this client, allowing them to better manage their mood swings and increase their overall quality of life.
References
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). APA.
Antokhin, E., Bardyurkina, V., Budza, V., Kryukova, E., & Baldina, O. (2010). Bipolar depression of the II type: Psychopathology, therapy. European Psychiatry, 25.
Depression and Bipolar Support Alliance (DBSA). (2020).
FAIR START. (2019). From affective illness to recovery: Student access to rapid treatment (FAIR START). Stanford Medicine.
Gabbard, G. O. (2014). Gabbard’s treatment of psychiatric disorders (5th ed.). American Psychiatric Publications.
Jones, S., Mulligan, L.D., Law, H., Dunn, G., Welford, M., Smith, G., & Morrison, A. P. (2012). A randomized controlled trial of recovery-focused CBT for individuals with early bipolar disorder. BMC Psychiatry, 12: 204.
Kern, B. (2014). Genetics of bipolar disorder. Applied Clinical Genetics, 7, 33-42.
NAMI. (2018). Retrieved June 30, 2020 from
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Wolters Kluwer.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). Cambridge University Press.
Ward, I. (2017). Pharmacologic options for bipolar disorder. Clinical Advisor, 20(3), 17–25.