chapter 7 case study for bipolar and related disorders giancarlo

Bipolar for Psychotherapists and Their Clients pp 95–162 Cite as

Difficult-to-Diagnose Case Studies of Bipolar Demonstrating Wide Variations in Presentations

• C. Raymond Lake 2  
• First Online: 06 October 2023

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Seventy case studies help in the recognition of Bipolar across a wide range of severity from successful Bipolar II clients to grandiose, paranoid, and psychotic Bipolar individuals. Mental health workers and families of severe Bipolars are at risk, and recommendations of steps for increased safety are offered. The severely mentally ill are at highest risk for violence against themselves and others.

Psychotic Bipolar killers have been inappropriately found sane and guilty of murder by the legal community.

• Wide variations in bipolar presentations
• Case studies
• Grandiosity
• Political leaders
• Mental health workers

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Lake, C.R. (2023). Difficult-to-Diagnose Case Studies of Bipolar Demonstrating Wide Variations in Presentations. In: Bipolar for Psychotherapists and Their Clients. Springer, Cham. https://doi.org/10.1007/978-3-031-38750-0_4

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Case Studies in Abnormal Psychology

Thomas f. oltmanns, michele t. martin, john m. neale, bipolar disorder - all with video answers.

Chapter Questions

Patients with bipolar disorder are often reluctant to take their medication because they don't want to give up periods of hypomania, when they feel exceptionally upbeat and productive. What would you say to a close friend with bipolar disorder who did not want to take medication?

Bipolar disorder can have a devastating impact on family relationships. Is there anything about the behavior of bipolar patients (especially during a manic episode) that might make it particularly difficult for a spouse to understand and accept the person's behavior as being part of a psychological disorder (rather than simply bad judgment)?

What evidence supports the decision to separate unipolar and bipolar mood disorders in the official classification system? In what ways are they different? In what ways are they similar? Can you think of other ways in which the mood disorders might be subdivided into more homogeneous subtypes?

Do you think that people who suffer from bipolar disorder are more likely than other people to seck out and participate in activities and occupations that are particularly stressful?

Case Presentation: A 23-Year-Old With Bipolar Disorder

Gus Alva, MD, DFAPA, presents the case of a 23-year-old female diagnosed with bipolar 1 disorder.

EP: 1 . Case Presentation: A 23-Year-Old With Bipolar Disorder

Ep: 2 . clinical impressions from the patient case, ep: 3 . clinical insights regarding the management of bipolar disorder.

Gus Alva, MD, DFAPA: Psychiatric Times presents this roundtable on the management of bipolar disorder, a phenomenal dialogue allowing clinicals a perspective regarding current trends and where we may be headed in the future.

This is an interesting case, as we take a look at this 23-year-old female who first comes in to see her psychiatrist with moderate depressive symptoms. At the time of the interview, her chief complaint included feeling like she’s lacking energy, she’s feeling depressed. She’s also reporting difficulty in paying attention, organizing her day, and accomplishing her tasks at work. Notably these symptoms started abruptly. Three weeks early, prior to that, she had been functioning better than usual, requiring very little sleep and getting more accomplished. Of significance, she reported two brief episodes of depression over the past 2 years. Each lasting about 2 months. And although the patient reported these depressive episodes as coming out of the blue, she learned after consulting with her therapist that they were related to significant psychosocial stress, stemming from the loss of her job and the deaths of 2 uncles, both of which were related to the COVID-19 pandemic. The patient reported that she still finds enjoyment talking to friends and socializing and she has hope of finding a new job and she’s constantly looking.

It’s noteworthy to bear in mind that in her first depressive episode she was treated with methylphenidate 25mg titrated up to 50 m and she stated feeling improved on this does with psychotherapy. Her second depressive episode, her does was bumped up to 100 mg which we saw improvement in depression, but she noted she felt a little activated and had trouble sleeping. With her third depressive episode, the therapist and PCP referred the patient over to a psychiatrist. Of great note should be her past psychological history: she was diagnosed with ADHD in middle school, during which time she responded well to methylphenidate. She continued to do well until her college years at which time she began experiencing difficulty falling asleep as well as irritability. At that time, she discontinued methylphenidate and was psychiatric drug free. She found that practicing mindfulness and yoga on a daily basis helped her residual ADHD symptoms. Of note, she had no history of suicidal thoughts or behavior, self-injurious behaviors, psychiatric hospitalization, or problems with substance abuse. Of note, regarding medical comorbidities, she was diagnosed a year earlier with type 2 diabetes, which was managed with metformin 1000 mg twice daily and her hemoglobin A1C was not poorly controlled. She was also diagnosed with high blood pressure 2 years earlier, that is managed by lisinopril 20 mg once daily. We noted that her BMI is 31, which is indicative of obesity. All other lab values were within normal limit. Significantly, her TSH was in the normal range and her urine toxicology screening was negative. Upon further querying of her family history, her maternal grandmother was diagnosed with a nervous breakdown and spent 2 months in a psychiatric hospital in her 30s. Her mother required little sleep, had a history of impulsive spending, and had a history of starting projects that she didn’t finish. The patient’s paternal uncles had a history of depression as well as alcohol abuse. Upon doing assessments, her PHQ9 is indicative of 18 points and her mood questionnaire she scored an 8.

Transcript Edited for Clarity

Assessing, Treating, and Managing Spring Mania in Patients With Bipolar Disorder

Blue Light Blockers: A Behavior Therapy for Mania

ADHD Research Roundup: March 1, 2024

Blue Light, Depression, and Bipolar Disorder

The Week in Review: February 19-23

Bipolar Disorder and Risk of Cardiometabolic Disease, Heart Failure, and Mortality

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Mental Health > Test 2 (case study quiz) - Chapter 26 - Bipolar and related disorders > Flashcards

Test 2 (case study quiz) - Chapter 26 - Bipolar and related disorders Flashcards

Bipolar disorders is characerized by….

mood swings from profound depression to extreme euphoria (mania)

delusions or hallucinations may be present onset of symptoms reflect a seasonal pattern.

What is the difference between mania and hypomania?

hypomania does not impair social or occupational functioning or require hospitalization like mania does

Bipolar dx can be labeled as I or II. What is the difference between the two?

(UPDATE AFTER LECTURE)

Bipolar I includes at least one MANIA or mixed episode + major depressive episodes

Bipolar II includes at least one major depressive episode + at least 1 hypomanic episode with normal moods in between.

What is a manic episode like?

Distinct period of persistently elevated, expansive or irritable mood and abnormally focused/persistent goal directed activity or energy last at least 1 week.

Inflated self esteem/grandiosity

decreased need for sleep.

more talkative

flight of ideas (racing thoughts)

distractibility

engaged in reckless behavior (buying srees, sexual indiscretion, foolish investments, etc)

mood distrubance that severely impairs socially/occupationally

What is a HYPOmanic episode like?

exactly like above EXCEPT mood disturbance DOES NOT impair the person socially/occupationally

Degrees of mania

See slide for more details

hypomania, acute, delirious

This disorder is a chronic mood disturbance of at least 2 years’ duration. The elevated period does not meed hypomania criteria and the depressed mood is not as severe as bipolar. What is the DO?

cyclothymic disorder

the individual is never without the symptoms for more than 2 months.

A person gets intoxicated on drugs, alcohol or medications which cause mood disturbances. This is known as

substance/medication induced bipolar disorder

How can bipolar be caused by another medical condition?

deficiency (depression) or increase (mania) in DA and NE (5ht remains low in both)

right sided lesions in limbic system is another example

see page 502 in ch 26

Medication for bipolar

_______ is antimanic, mood stabilizer. It requires an ekg and intake of salt and water. It is used to treat mania.

Lithium (considered the gold standard)

Remember to check the blood lithium levels daily!

T or F: The calcium channel blocker Verapamil can be used to treat Bipolar depression.

_________ is an anticonvulsant used to treat bipolar disease. it is good for rapid cyclers.

Carbamazpine (Tegretol, Equetro)

Know TEGRETOL acronym

T - Trigeminal neurolgia = tonic clonic seizures (do not stop abruptly)

E - Evaluate for UE: anorexia, nausea, dizziness, sedation, heart attack, sore throat, blood dyscrasias.

G - Give with food, milk to reduce GI upset

R - Review levels, maintain between 4-12

E - Evaluate hepatic and renal function (and for anorexia - sign for toxicity)

T - Tablet = chewable, do not swallow whole! Or take extended release

O - Open and mis with food (extended release)

L - Look for many drug/drug interactions (toxic with lithium)

T or F: 2nd and 3rd generation antipsychotics and atypicals may be used to treat bipolar disorder.

approved for mania and may also be effective against depressive symptoms. Most atypicals can lead to weight gain and increase the incidence of type II diabetes.

________ ( ______ ) works well in patients with bipolar 2.

aripiprazole (Abilify)

Two i’s - bipolar 2

Hip hip hurray, I have the ability 2 feel better

Paroxetine (Paxil) is what type of med? How does it effect bipolar disorder patients?

Works well, decreases switching to other antidepressants.

Which group of antidepressants should be avoided in bipolar treatment?

There are three stages of mania ranging from hypomania to delirious mania. explain MOOD we expect to see in each stage.

Stage I: Hypomania - Cheerful and expansive (with underlying irritability that surfaces rapidly when desires unfulfilled); volatile and fluctuating.

Stage II: Acute Mania - characterized by euphoria and elation. Appears to be on continuous high. Always subject to frequent variation.

Stage III: Delirious Mania - very labile. Might go from despair to urestrained merriment and ectasy. Might be irritable or indifferent. Panic anxiety may be evident.

There are three stages of mania ranging from hypomania to delirious mania. explain COGNITION AND PERCEPTION we expect to see in each stage.

Stage I: Hypomania - perception of self is exalted. Easily distracted by irrelevant stimuli.

Stage II: Acute Mania - flight of ideas (fragmented, psychotic, disjointed); abrupt topic changes.

Stage III: Delirious Mania - clouding of consciousness + confusion, disorientation and sometimes stupor.

There are three stages of mania ranging from hypomania to delirious mania. explain ACTIVITY AND BEHAVIOR we expect to see in each stage.

Stage I: Hypomania - extroverted, sociable, talk loudly and inappropriately. increased libido.

Stage II: Acute Mania - xcessive activity. excessive spending poor impulse control. manipulate others. energy seems inexhaustible. no need for sleep. Dress may be disorganized, flamboyant, bizarre and excessive.

Stage III: Delirious Mania - purposeless movements, frenzied, agitated. Intervention or death.

T or F: bipolar persons should be treated by someone of the same sex

True. Consistent person of same sex.

What type of foods should you have available to bipolar DO pts?

things that can be eaten on the run; finger foods.

A person in the manic phase will have a short attention span. What can we do to communicate?

Walk and talk with patient.

Reduce stimuli

SECLUSION (away from nurses station - too much noise)

Use short simple sentences

T or F: You should be strict with rules when it comes to bipolar patients.

True. no special favors or privileges. Patient may try to charm you to fulfill their own desires.

Patient may try to make sexual advances - set boundaries verbally and physically (ask colleague to help. Do not go “off-site” for sessions). redefine your role as a reminder!

Mental Health (29 decks)

• Test 1 - Therapeutic Communication
• Test 1 - Chapter 18, 19
• Test 1 - Chapter 3 - Theories of Personality Development (Theory PPT also)
• Defense Mechanisms (From Chapter 2)
• Ignore - Thursday - Chapters 2,9,10,11 (Also see therapeutic communication above)
• Test 1 - Substance abuse
• Test 1 - Medications for Mental Health
• Test 1 - Eating Disorders
• Test 1 - Legal
• Axis I - IV
• Test 1 - Mental Status Exam
• Test 1 - Leadership Types, Group development phases
• Test 1 - Therapeutic communication techniques and individual therapy phases
• Test 2 (Case study quiz) Chapter 25 - Depressive disorders
• Test 2 (case study quiz) - Chapter 26 - Bipolar and related disorders
• Test 2 (Case Study QUiz) - Chapter 27 - Anxiety, OCD, and related DO's AND Chapter 13 - crisis
• Test 2 (Case Study Quiz) - Chapter 29 - Somatic Symptom and Dissociative Disorders
• Test 2 - Chapter 28 - Trauma-related and Stressor-related (PTSD, Acute Stress and Adjustmen DO)
• NEW!! Psych Meds - ANTIPSYCHOTICS - with both names, cuz dammit we need to pass!!
• NEW!! Psych Meds - ANTIDEPRESSANTS - with both names, cuz dammit we need to pass!!
• NEW!! Psych Meds - ANTICONVULSANTS - With both names, cuz dammit we need to pass.
• NEW!! Psych Meds - ANXYOLTICS
• NEW!! Psych Meds - ACh Inhibitors
• NEW!! Psych Meds - Stimulants
• Ch. 24 - Schizophrenia
• Ch. 22 Neurocognitive Disorders
• Ch. 33 - Children and Adolescents
• Final - Meds based on Disease/Disorder
• Ch. 35 - Survivors of Abuse and Neglect
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