sample case study for bipolar disorder

Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

• Theresa Cerulli, MD
• Tina Matthews-Hayes, DNP, FNP, PMHNP

Custom Around the Practice Video Series

Experts in psychiatry review the case of a 27-year-old woman who presents for evaluation of a complex depressive disorder.

EP: 1 . Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

Ep: 2 . clinical significance of bipolar disorder, ep: 3 . clinical impressions from patient case #1, ep: 4 . diagnosis of bipolar disorder, ep: 5 . treatment options for bipolar disorder, ep: 6 . patient case #2: 47-year-old man with treatment resistant depression (trd), ep: 7 . patient case #2 continued: novel second-generation antipsychotics, ep: 8 . role of telemedicine in bipolar disorder.

Michael E. Thase, MD : Hello and welcome to this Psychiatric Times™ Around the Practice , “Identification and Management of Bipolar Disorder. ”I’m Michael Thase, professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Joining me today are: Dr Gustavo Alva, the medical director of ATP Clinical Research in Costa Mesa, California; Dr Theresa Cerulli, the medical director of Cerulli and Associates in North Andover, Massachusetts; and Dr Tina Matthew-Hayes, a dual-certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Today we are going to highlight challenges with identifying bipolar disorder, discuss strategies for optimizing treatment, comment on telehealth utilization, and walk through 2 interesting patient cases. We’ll also involve our audience by using several polling questions, and these results will be shared after the program.

Without further ado, welcome and let’s begin. Here’s our first polling question. What percentage of your patients with bipolar disorder have 1 or more co-occurring psychiatric condition? a. 10%, b. 10%-30%, c. 30%-50%, d. 50%-70%, or e. more than 70%.

Now, here’s our second polling question. What percentage of your referred patients with bipolar disorder were initially misdiagnosed? Would you say a. less than 10%, b. 10%-30%, c. 30%-50%, d. more than 50%, up to 70%, or e. greater than 70%.

We’re going to go ahead to patient case No. 1. This is a 27-year-old woman who’s presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode. It began back in the fall, and she described the episode as occurring right “out of the blue.” Further discussion revealed, however, that she had talked with several confidantes about her problems and that she realized she had been disappointed and frustrated for being passed over unfairly for a promotion at work. She had also been saddened by the unusually early death of her favorite aunt.

Now, our patient has a past history of ADHD [attention-deficit/hyperactivity disorder], which was recognized when she was in middle school and for which she took methylphenidate for adolescence and much of her young adult life. As she was wrapping up with college, she decided that this medication sometimes disrupted her sleep and gave her an irritable edge, and decided that she might be better off not taking it. Her medical history was unremarkable. She is taking escitalopram at the time of our initial evaluation, and the dose was just reduced by her PCP [primary care physician]from 20 mg to 10 mg because she subjectively thought the medicine might actually be making her worse.

On the day of her first visit, we get a PHQ-9 [9-item Patient Health Questionnaire]. The score is 16, which is in the moderate depression range. She filled out the MDQ [Mood Disorder Questionnaire] and scored a whopping 10, which is not the highest possible score but it is higher than 95% of people who take this inventory.

At the time of our interview, our patient tells us that her No. 1 symptom is her low mood and her ease to tears. In fact, she was tearful during the interview. She also reports that her normal trouble concentrating, attributable to the ADHD, is actually substantially worse. Additionally, in contrast to her usual diet, she has a tendency to overeat and may have gained as much as 5 kg over the last 4 months. She reports an irregular sleep cycle and tends to have periods of hypersomnolence, especially on the weekends, and then days on end where she might sleep only 4 hours a night despite feeling tired.

Upon examination, her mood is positively reactive, and by that I mean she can lift her spirits in conversation, show some preserved sense of humor, and does not appear as severely depressed as she subjectively describes. Furthermore, she would say that in contrast to other times in her life when she’s been depressed, that she’s actually had no loss of libido, and in fact her libido might even be somewhat increased. Over the last month or so, she’s had several uncharacteristic casual hook-ups.

So the differential diagnosis for this patient included major depressive disorder, recurrent unipolar with mixed features, versus bipolar II disorder, with an antecedent history of ADHD. I think the high MDQ score and recurrent threshold level of mixed symptoms within a diagnosable depressive episode certainly increase the chances that this patient’s illness should be thought of on the bipolar spectrum. Of course, this formulation is strengthened by the fact that she has an early age of onset of recurrent depression, that her current episode, despite having mixed features, has reverse vegetative features as well. We also have the observation that antidepressant therapy has seemed to make her condition worse, not better.

Transcript Edited for Clarity

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.

Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.

Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

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Real Life Bipolar Disorder: A Case Study of Susan

Bipolar disorder is a complex and often misunderstood mental health condition that affects millions of individuals worldwide. For those living with bipolar disorder, the highs and lows of life can be dizzying, as they navigate through periods of intense mania and debilitating depression. To truly grasp the impact of this disorder, it’s crucial to explore real-life experiences and the stories of those who have dealt firsthand with its challenges.

In this article, we delve into the fascinating case study of Susan, a woman whose life has been profoundly shaped by her bipolar disorder diagnosis. By examining Susan’s journey, we aim to shed light on the realities of living with this condition and the strategies employed to manage and treat it effectively.

But before we plunge deeper into Susan’s story, let’s first gain a comprehensive understanding of bipolar disorder itself. We’ll explore the formal definition, the prevalence of the condition, and its impact on both individuals and society as a whole. This groundwork will set the stage for a more insightful exploration of Susan’s experience and provide valuable context for the subsequent sections of this article.

Bipolar disorder is more than just mood swings; it is a condition that can significantly disrupt an individual’s life, relationships, and overall well-being. By studying a real-life case like Susan’s, we can gain a personal insight into the multifaceted challenges faced by those with bipolar disorder and the importance of effective treatment and support systems. In doing so, we hope to foster empathy, inspire early diagnosis, and contribute to the advancement of knowledge about bipolar disorder’s complexities.

The Case of Susan: A Real Life Experience with Bipolar Disorder

Susan’s story provides a compelling illustration of the impact that bipolar disorder can have on an individual’s life. Understanding her background, symptoms, and the effects of the disorder on her daily life can provide valuable insights into the challenges faced by those with bipolar disorder.

Background Information on Susan

Susan, a thirty-eight-year-old woman, was diagnosed with bipolar disorder at the age of twenty-five. Her early experiences with the disorder were characterized by periods of extreme highs and lows, often resulting in strained relationships and an inability to maintain steady employment. Susan’s episodes of mania frequently led to impulsive decision-making, excessive spending sprees, and risky behaviors. On the other hand, her depressive episodes left her feeling hopeless, fatigued, and unmotivated.

Symptoms and Diagnosis of Bipolar Disorder in Susan

To receive an accurate diagnosis, Susan underwent a thorough examination by mental health professionals. The criteria for diagnosing bipolar disorder include significant and persistent mood swings, alternating between periods of mania and depression. Susan exhibited classic symptoms of bipolar disorder, such as elevated mood, increased energy, racing thoughts, decreased need for sleep, and reckless behavior during her manic episodes. These episodes were interspersed with periods of deep sadness, loss of interest in activities, and changes in appetite and sleep patterns during depressive phases.

Effects of Bipolar Disorder on Susan’s Daily Life

Living with bipolar disorder presents unique challenges for Susan. The unpredictable shifts in her mood and energy levels significantly impact her ability to function in both personal and professional spheres. During manic phases, Susan experiences heightened productivity, creativity, and confidence, often leading her to take on excessive responsibilities and projects. However, these periods are eventually followed by crashes into depressive episodes, leaving her unable to complete tasks, maintain relationships, or even perform routine self-care. The constant fluctuations in her emotional state make it difficult for Susan to establish a sense of stability and predictability in her life.

Susan’s struggle with bipolar disorder is not uncommon. Many individuals with this condition face similar obstacles in their daily lives, attempting to manage the debilitating highs and lows while striving for a sense of normalcy. By understanding the real-life implications of bipolar disorder, we can more effectively tailor our support systems and treatment options to address the needs of individuals like Susan. In the next section, we will explore the various approaches to treating and managing bipolar disorder, providing potential strategies for improving the quality of life for those living with this condition.

Treatment and Management of Bipolar Disorder in Susan

Managing bipolar disorder requires a multifaceted approach that combines psychopharmacological interventions, psychotherapy, counseling, and lifestyle modifications. Susan’s journey towards finding effective treatment and management strategies highlights the importance of a comprehensive and tailored approach.

Psychopharmacological Interventions

Pharmacological interventions play a crucial role in stabilizing mood and managing symptoms associated with bipolar disorder. Susan’s treatment plan involved medications such as mood stabilizers, antipsychotics, and antidepressants. These medications aim to regulate the neurotransmitters in the brain associated with mood regulation. Susan and her healthcare provider closely monitored her medication regimen and made adjustments as needed to achieve symptom control.

Psychotherapy and Counseling

Psychotherapy and counseling provide individuals with bipolar disorder a safe space to explore their thoughts, emotions, and behaviors. Susan engaged in cognitive-behavioral therapy (CBT), which helped her identify and challenge negative thought patterns and develop healthy coping mechanisms. Additionally, psychoeducation in the form of group therapy or support groups allowed Susan to connect with others facing similar challenges, fostering a sense of community and reducing feelings of isolation.

Lifestyle Modifications and Self-Care Strategies

In addition to medical interventions and therapy, lifestyle modifications and self-care strategies play a vital role in managing bipolar disorder. Susan found that maintaining a stable routine, including regular sleep patterns, exercise, and a balanced diet, helped regulate her mood. Avoiding excessive stressors and implementing stress management techniques, such as mindfulness meditation or relaxation exercises, also supported her overall well-being. Engaging in activities she enjoyed, nurturing her social connections, and setting realistic goals further enhanced her quality of life.

Striving for stability and managing bipolar disorder is an ongoing process. What works for one individual may not be effective for another. It is crucial for individuals with bipolar disorder to work closely with their healthcare providers and engage in open communication about treatment options and progress. Fine-tuning the combination of psychopharmacological interventions, therapy, and self-care strategies is essential to optimize symptom control and maintain stability.

Understanding the complexity of treatment and management helps foster empathy for individuals like Susan, who face the daily challenges associated with bipolar disorder. It underscores the importance of early diagnosis, accessible mental health care, and ongoing support systems to enhance the lives of individuals living with this condition. In the following section, we will explore the various support systems available to individuals with bipolar disorder, including family support, peer support groups, and the professional resources that contribute to their well-being.

Support Systems for Individuals with Bipolar Disorder

Navigating the challenges of bipolar disorder requires a strong support system that encompasses various sources of assistance. From family support to peer support groups and professional resources, these networks play a significant role in helping individuals manage their condition effectively.

Family Support

Family support is vital for individuals with bipolar disorder. Understanding and empathetic family members can provide emotional support, monitor medication adherence, and help identify potential triggers or warning signs of relapse. In Susan’s case, her family played a crucial role in her recovery journey, providing a stable and nurturing environment. Education about bipolar disorder within the family helps foster empathy, reduces stigma, and promotes open communication.

Peer Support Groups

Peer support groups provide individuals with bipolar disorder an opportunity to connect with others who share similar experiences. Sharing personal stories, strategies for coping, and offering mutual support can be empowering and validating. In these groups, individuals like Susan can find solace in knowing that they are not alone in their struggles. Peer support groups may meet in-person or virtually, allowing for easier access to support regardless of physical proximity.

Professional Support and Resources

Professional support is crucial in the management of bipolar disorder. Mental health professionals, such as psychiatrists, psychologists, and therapists, provide expertise and guidance in developing comprehensive treatment plans. Regular therapy sessions allow individuals like Susan to explore emotional challenges and develop healthy coping mechanisms. Psychiatrists closely monitor medication effectiveness and make necessary adjustments. Additionally, case managers or social workers can assist with navigating the healthcare system, accessing resources, and connect individuals with other community services.

Beyond direct professional support, there are resources and organizations dedicated to bipolar disorder education, advocacy, and support. Online forums, websites, and helplines provide information, guidance, and a sense of community. These platforms allow individuals to access information at any time and connect with others who understand their unique experiences.

Support systems for bipolar disorder are crucial in empowering individuals and enabling them to lead fulfilling lives. They contribute to reducing stigma, providing emotional support, and ensuring access to resources and education. Through these support systems, individuals with bipolar disorder can gain self-confidence, develop effective coping strategies, and improve their overall well-being.

In the next section, we explore the significance of case studies in understanding bipolar disorder and how they contribute to advancing research and knowledge in the field. Specifically, we will examine how Susan’s case study serves as a valuable contribution to furthering our understanding of this complex disorder.

The Importance of Case Studies in Understanding Bipolar Disorder

Case studies play a vital role in advancing our understanding of bipolar disorder and its complexities. They offer valuable insights into individual experiences, treatment outcomes, and the overall impact of the condition on individuals and society. Susan’s case study, in particular, provides a unique perspective that contributes to broader research and knowledge in the field.

How Case Studies Contribute to Research

Case studies provide an in-depth examination of specific individuals and their experiences with bipolar disorder. They allow researchers and healthcare professionals to observe patterns, identify commonalities, and gain valuable insights into the factors that influence symptom presentation, treatment response, and prognosis. By analyzing various case studies, researchers can generate hypotheses and refine treatment approaches to optimize outcomes for individuals with bipolar disorder.

Case studies are particularly helpful in documenting rare or atypical presentations of bipolar disorder. They shed light on lesser-known subtypes, such as rapid-cycling bipolar disorder or mixed episodes, contributing to a more comprehensive understanding of the condition. Case studies also provide opportunities for clinicians and researchers to discuss unique challenges and discover innovative interventions to improve treatment outcomes.

Susan’s Case Study in the Context of ATI Bipolar Disorder

Susan’s case study is an example of how individual experiences can inform the development of Assessment Technologies Institute (ATI) for bipolar disorder. By examining her journey, researchers can analyze treatment approaches, evaluate the effectiveness of various interventions, and develop evidence-based guidelines for managing bipolar disorder.

Susan’s case study provides rich information about the impact of medication, psychotherapy, and lifestyle modifications on symptom control and overall well-being. It offers valuable insights into the benefits and limitations of specific interventions, highlighting the importance of personalized treatment plans tailored to individual needs. Additionally, Susan’s case study can contribute to ongoing discussions about the role of support systems and the integration of peer support groups in managing and enhancing the lives of individuals with bipolar disorder.

The detailed documentation of Susan’s experiences serves as a powerful tool for healthcare providers, researchers, and individuals living with bipolar disorder. It highlights the complexities and challenges associated with the condition while fostering empathy and understanding among various stakeholders.

Case studies, such as Susan’s, play a crucial role in enhancing our understanding of bipolar disorder. They provide insights into individual experiences, treatment approaches, and the impact of the condition on individuals and society. Through these case studies, we can cultivate empathy for individuals with bipolar disorder, advocate for early diagnosis and effective treatment, and contribute to advancements in research and knowledge.

By illuminating the realities of living with bipolar disorder, we acknowledge the need for accessible mental health care, support systems, and evidence-based interventions. Susan’s case study exemplifies the importance of a comprehensive approach to managing bipolar disorder, integrating psychopharmacological interventions, psychotherapy, counseling, and lifestyle modifications.

Moving forward, it is essential to continue studying cases like Susan’s and explore the diverse experiences within the bipolar disorder population. By doing so, we can foster empathy, encourage early intervention and personalized treatment, and contribute to advancements in understanding bipolar disorder, ultimately improving the lives of individuals affected by this complex condition.

Empathy and Understanding for Individuals with Bipolar Disorder

Developing empathy and understanding for individuals with bipolar disorder is crucial in fostering a supportive and inclusive society. By recognizing the unique challenges they face and the complexity of their experiences, we can better advocate for their needs and provide the necessary resources and support.

It is important to understand that bipolar disorder is not simply a matter of mood swings or being “moody.” It is a chronic and often debilitating mental health condition that affects individuals in profound ways. The extreme highs of mania and the lows of depression can disrupt relationships, employment, and overall quality of life. Developing empathy means acknowledging that these struggles are real and offering support and understanding to those navigating them.

Encouraging Early Diagnosis and Effective Treatment

Early diagnosis and effective treatment are key factors in managing bipolar disorder and reducing the impact of its symptoms. Encouraging individuals to seek help and reducing the stigma associated with mental illness are crucial steps toward achieving early diagnosis. Increased awareness campaigns and education can empower individuals to recognize the signs and symptoms of bipolar disorder in themselves or their loved ones, facilitating timely intervention.

Once diagnosed, providing access to quality mental health care and ensuring individuals receive appropriate treatment is essential. Bipolar disorder often requires a combination of pharmacological interventions, psychotherapy, and lifestyle modifications. By advocating for comprehensive treatment plans and promoting ongoing care, we can help individuals with bipolar disorder achieve symptom control and improve their overall well-being.

The Role of Case Studies in Advancing Knowledge about Bipolar Disorder

Case studies, like Susan’s, play a significant role in advancing knowledge about bipolar disorder. They provide unique insights into individual experiences, treatment outcomes, and the wider impact of the condition. Researchers and healthcare providers can learn from these individual cases, developing evidence-based guidelines and refining treatment approaches.

Additionally, case studies contribute to reducing stigma by providing personal narratives that humanize the disorder. They showcase the challenges faced by individuals with bipolar disorder and highlight the importance of support systems, empathy, and understanding. By sharing these stories, we can help dispel misconceptions and promote a more compassionate approach toward mental health as a whole.

In conclusion, developing empathy and understanding for individuals with bipolar disorder is essential. By recognizing the complexity of their experiences, advocating for early diagnosis and effective treatment, and valuing the insights provided by case studies, we can create a society that supports and uplifts those with bipolar disorder. It is through empathy and education that we can reduce stigma, promote accessible mental health care, and improve the lives of those affected by this condition.In conclusion, gaining a comprehensive understanding of bipolar disorder is crucial in order to support individuals affected by this complex mental health condition. Through the real-life case study of Susan, we have explored the numerous facets of bipolar disorder, including its background, symptoms, and effects on daily life. Susan’s journey serves as a powerful reminder of the challenges individuals face in managing the highs and lows of bipolar disorder and emphasizes the importance of effective treatment and support systems.

We have examined the various approaches to treating and managing bipolar disorder, including psychopharmacological interventions, psychotherapy, and lifestyle modifications. Understanding the role of these treatments and the need for personalized care can significantly improve the quality of life for individuals like Susan.

Support systems also play a crucial role in helping those with bipolar disorder navigate the complexities of the condition. From family support to peer support groups and access to professional resources, fostering a strong network of assistance can provide the necessary emotional support, education, and guidance needed for individuals to effectively manage their symptoms.

Furthermore, case studies, such as Susan’s, contribute to advancing our knowledge about bipolar disorder. By delving into individual experiences, researchers gain valuable insights into treatment outcomes, prognosis, and the impact of the condition on individuals and society as a whole. These case studies foster empathy, reduce stigma, and contribute to the development of evidence-based guidelines and interventions that can improve the lives of individuals with bipolar disorder.

In fostering empathy and promoting early diagnosis, effective treatment, and ongoing support, we create a society that actively embraces and supports individuals with bipolar disorder. By encouraging understanding, reducing stigma, and prioritizing mental health care, we can ensure that those affected by bipolar disorder receive the support and resources necessary to lead fulfilling and meaningful lives. Through empathy, education, and continued research, we can work towards a future where individuals with bipolar disorder are understood, valued, and empowered to thrive.

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A Closer Look: Case Study on Bipolar Mood Disorder

In the days of Hippocrates, you'd likely attribute the erratic behaviors associated with bipolar mood disorder to an imbalance of bodily humors, but today, you know it's far more complex than that.

As you peruse the pages of this case study, you'll join the intricate journey through the life of a patient with bipolar disorder, whose story might resonate more deeply than you'd expect. You'll witness the oscillation between the highs of mania and the lows of depression, and understand why recognizing the nuances of this condition is pivotal.

The chronicle ahead lays bare the challenges of diagnosis, the trials of treatment, and the reality of living with a mood disorder that's as unpredictable as the weather in April.

Consider for a moment the impact of a single misstep in the delicate dance of managing bipolar disorder—you'll soon see why this case demands your attention, and perhaps, why it might change the way you view mental health care forever.

Key Takeaways

• Bipolar disorder is a complex mental health condition characterized by significant mood swings.
• Family support is critical in managing mental health challenges.
• Understanding the rhythm of mood fluctuations is crucial for managing bipolar disorder.
• Creating a consistent routine and having a strong support system are key to managing daily life with bipolar disorder.

Understanding Bipolar Disorder

Bipolar disorder is a complex mental health condition characterized by significant mood swings that can impact a person's thoughts, feelings, and behaviors. If you're grappling with this, you're not alone; it's a challenge faced by many.

Understanding bipolar mood disorders involves recognizing the pendulum-like shift between manic and depressive episodes. You may wonder if your intense high energy levels or periods of depression are signs of this condition. The diagnosis of bipolar is a critical step and involves a thorough assessment by a healthcare professional. They'll look at your symptoms, how long they last, and how they're affecting your life. It's not just about feeling up and down; it's a pattern that can wreak havoc if not properly managed.

To keep these fluctuations in check, a mood stabilizer is often prescribed. These medications help balance your moods and prevent the extreme highs and lows associated with bipolar disorder. It's essential to adhere to the treatment plan and communicate openly with your healthcare provider about how you're feeling.

Patient Background Profile

Understanding the nuances of bipolar disorder sets the stage for exploring the personal journey of Gary, a 19-year-old whose life was upended by this mental health challenge. Diagnosed with bipolar disorder, Gary's world shifted dramatically during his college years. His manic episode led to a sudden withdrawal from college and an unexpected switch from engineering to philosophy. This was a significant departure from his usual behavior, marked by reduced sleep, engaging in long, intense conversations, and exhibiting grandiose beliefs.

Gary's adolescent years were peppered with warning signs, including periods of withdrawal and depression, which may have hinted at his underlying condition. A family history of mental health issues can often be a precursor to such diagnoses, though Gary's case doesn't explicitly mention this. However, it's known that family support can be critical, and Gary's parents are no exception; they're eager to be involved in his treatment, recognizing early signs of anxiety and depression in his past.

The disruption in Gary's academic performance and personal relationships necessitated a robust treatment plan. Placed on a mood stabilizer and antipsychotic medication, Gary was also recommended adjunctive psychotherapy to help manage his condition and work towards stable behavior and improved functioning.

Episode Chronology

Mapping out the episode chronology in Gary's journey with bipolar disorder reveals the patterns and frequency of his mood swings, providing invaluable insights for managing his care. You'll notice that his major depressive disorder phases often follow intense hypomanic episodes, suggesting a cycle that dictates the rhythm of his life.

Understanding Gary's episode chronology, you'll see that the periods between his mood swings aren't just random; they're clues to what triggers his episodes. Maybe it's stress, lack of sleep, or even changes in the seasons. By keeping track of these patterns, you've got a better shot at predicting and heading off future episodes.

Treatment Approaches

Having explored the rhythm of Gary's mood fluctuations, it's crucial now to focus on how best to manage his bipolar disorder through effective treatment approaches. Treating bipolar can be complex, and it requires a tailored plan that takes into account his unique needs. Here's what you need to keep in mind:

• Medication Management
• Mood stabilizers are often the first line of defense; valproic acid, for instance, can be effective in controlling mood swings.
• Antipsychotics may be added for additional symptom control.
• Regular monitoring for side effects is key to maintaining overall health.
• Psychoeducation
• Understanding bipolar disorder and its management is empowering for you and your family.
• Knowledge about triggers and symptoms aids in early intervention.
• Collaborative Care
• Psychiatrists, therapists, and primary care providers should all be in sync when managing bipolar disorder.
• Communication between healthcare professionals ensures a cohesive and comprehensive approach.

Managing Daily Life

You'll find that creating a consistent routine is key to managing your daily life with bipolar mood disorder.

It's also vital to have a strong support system in place, as the people around you can provide essential help and understanding.

These strategies will help you maintain stability and manage the ups and downs that come with your condition.

Routine Structuring Strategies

Implementing a structured daily routine can significantly ease the management of bipolar disorder symptoms, offering stability and predictability in your life. Here's how you can tailor your daily routine to manage mood dysregulation effectively:

• Set regular times for:
• *Sleep:* Consistent sleep patterns stabilize your mood.
• *Meals:* Regular meals help maintain energy levels.
• *Exercise:* Physical activity is key in managing stress.

Prioritizing these aspects of your routine can lead to better adherence to adequate treatment and improve your overall well-being.

Support System Importance

Leaning on a robust support system, you can navigate the complexities of daily life with bipolar disorder more effectively, ensuring a network of care that promotes stability and well-being. Your support system's importance can't be overstated—it's the foundation that holds you steady amidst the shifting sands of emotions and challenges.

Here's a snapshot of how a strong support network can help you manage essential aspects of your life:

Reflecting on Progress

Reflecting on your progress with bipolar mood disorder, it's essential to evaluate how diagnosis and treatment have influenced your daily life and mental health. You've likely noticed changes in your clinical presentations, and it's crucial to track these shifts. Consider the following:

• Patient Reported Outcomes
• *Symptom Management*: Have you experienced a reduction in the frequency or severity of mood episodes?
• *Quality of Life*: Are you finding more stability and enjoyment in your daily activities?
• *Self-Awareness*: Have you become more attuned to your triggers and early warning signs?

Adherence to your treatment plan plays a pivotal role in your journey. Engaging with your healthcare provider allows for necessary adjustments and ensures that your mental health remains a priority. Comorbid conditions and lifestyle factors also significantly impact your treatment response, necessitating a holistic approach to your well-being.

Regular monitoring is key to managing side effects and maintaining overall stability. By collaborating with your care team and being proactive about your health, you're laying the groundwork for continued progress and a more balanced life.

Frequently Asked Questions What Are Some Interesting Research Topics on Bipolar Disorder?

You might explore the genetic basis of bipolar disorder, the effectiveness of psychotherapy combined with medication, or the impact of lifestyle factors on symptom management in your research.

What Is the Average Age of Death for a Person With Bipolar Disorder?

You've asked about the average age of death for someone with bipolar disorder. It's sadly shorter, typically 9 to 20 years less than the general population, ranging from 47 to 61 years old.

What Is the Leading Cause of Death in Bipolar People?

You should know that the leading cause of death in bipolar people is suicide, a tragic consequence that underscores the importance of vigilant care and support for those managing this condition.

How Does Bipolar Disorder Affect Someone's Everyday Life?

Bipolar disorder is like an unpredictable storm, disrupting your daily life with extreme mood swings that can hinder your work, strain relationships, and make sticking to routines feel nearly impossible.

You've journeyed through the labyrinth of bipolar disorder, navigating its highs and lows alongside our patient. From the chaos of misdiagnosis to the anchor of tailored therapy, you've seen the transformation. Like a time traveler who's witnessed history's pivotal turn, you understand now how crucial timely intervention is.

Let's celebrate the milestones, recognizing that with acceptance and consistent care, managing bipolar disorder isn't just a possibility—it's a reality etched in the annals of personal triumph.

Daniel Logan is a renowned author and mental health expert who specializes in psychology and mental health topics. Daniel holds a degree in psychology from the University of California, Los Angeles (UCLA). With years of experience in the field, he has become a trusted voice in the industry, sharing insights and knowledge on a variety of mental health issues.

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H and P write up: Bipolar patient

In my psych clinical correlations class, I was given the opportunity to create my own H&P case of a fictional psych patient. I had a lot of fun creating the case and being able to act as the patient as my 2 other classmates interviewed me. This is what I came up with……

Markenzie Jean-Baptiste

Rotation#3: Psychology

History and Physical

Identifying Data :

Nationality : African American

Date & Time : 4/08/2020 @ 4:45pm

Location : Queens Hospital Psych Emergency Department

Source of Referral : Police officer, mother

Source of Information : Self  and mother- both reliable

Mode of Transport : ambulatory

Chief Complaint : “I got into a fight at school today x 2 hours ago”

History of Present Illness :

Ms. B.S. is a 20 y/o AA female, presents to Psych ED today with contusion to the LT side of face s/p getting into a fight at school with another girl x 2 hours ago. PT reports that the girl she fought stole her boyfriend from her about 1 week ago and when she saw her today, she approached her and they began to fight. PT reports that she was punched on the LT side of her face but denies any other injuries from the fight. Pt reports that she started having feelings of depression and problems controlling her mood about 2 months ago. She reports going days without sleeping, began having trouble concentrating in school and stopped going to classes regularly in the past 2 months. Reports that she has been going to dance parties more frequently and would have 3-4 alcoholic drinks on Saturday nights usually. Also reports that she started having unprotected sexual relationships with 3 different men in the past 2 months. PT reports that she has been going on shopping spree, spending her money on new outfits for when she goes out to party, and this has caused her to have high credit card balance. PT reports that all of this has had her feeling more depressed and she thinks that her mother is ashamed of her. Patients mother reports that pt’s mood has been out of control in the past 2 months and her emotions have been “up and down. Pt’s mother reports that she took her daughter to see a psychiatrist at an Urgent Care x 1 month ago after she got into a fight with a girl at school and was yelling at other students and teachers. Pt’s mother reports that pt was diagnosed with Bipolar disorder and prescribed lithium 300mg TID. PT reports that she took lithium for 1 week in which she had less changes in her mood, was less depressed and slept better during this time but she lost the medication 3 weeks ago and has not taken it since. Pt’s mother reports that prior to this episode 2 months ago, pt had seemed depressed sometimes, but she did not know that pt had some of these behavioral problems. PT’s mother reports that pt’s older sister had similar mood swings but never was evaluated by a psychiatrist. PT denies suicidal or homicidal thoughts, auditory or visual hallucination, or paranoia ideations. Denies headache, syncope, LOC, vision changes, chest pain, SOB, fever, chills.

Past Medical History:

Present illness: Bipolar Disorder w/ manic episode

Past illness:  none

Hospitalizations: none

Medications:

Lithium 300 mg tablet, 1 tab TID- last dose was 3 weeks ago.

Denies taking any other medications.

Allergies :

Denies drug allergies, food allergies or environmental allergies.

Past Surgical History:

Denies injuries, past surgeries and transfusions.

Immunizations

Flu vaccine yearly, all other childhood immunizations are up to Date

Family History:

Mother: 44, alive- denies hx HTN or diabetes

Father: 48, alive- hx denies hx HTN or diabetes

Sister: 26, alive and well

Brother: 16, alive and well

Social History:

Ms. BS is a 20 y/o AA female who lives at home with her mother and younger brother on the 3 rd floor of a 5th floor apartment building. PT attends York College and is studying business administration with plans of opening up her own hair salon in the future. PT’s mother and father have been divorced for about 6 years. Pt’s mother reports that pt’s sister who is married has had mood swings as well but never was evaluated by a psychiatrist.

Habits:  PT admits to drinking alcohol socially- 3-4 alcoholic drinks weekly at parties. Denies ever smoking cigarettes. Denies ever smoking marijuana or using illicit drugs.

Marital History: single

Sexual History: PT reports that she started having unprotected sexual relationships with 3 different men in the past 2 months. Denies any hx of known STD. Does not recall her last STD testing.

Diet: Reports that she consumes a balanced diet.

Sleep: Reports that she has days where she gets 5 hours of sleep a night but also times when she does not sleep for 1-2 days at a time. Reports that she has had difficulty falling asleep and this started about 2 months ago.

Exercise:  Reports that she goes to the gym 1-2 times a week but this is not consistent.

Review of Symptoms:

General : Denies fever, chills, night sweats, fatigue, weakness, loss of appetite, recent weight gain or loss

Skin, hair, nails : (+) contusion to LT side of face over cheek Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution

Head: Denies h eadache, vertigo, head trauma, unconsciousness, coma, fracture

Eyes:Denies visual disturbances, fatigue, lacrimation, photophobia, pruritus,

Ears: Denies deafness, pain, discharge, tinnitus, hearing aids

Nose/Sinuses: Denies discharge, epistaxis, obstruction

Mouth and throat: Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures, last dental exam

Neck: Denies localized swelling/lumps, stiffness/decreased range of motion

Pulmonary: Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND

Cardiovascular: Denies chest pain, HTN, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur

Gastrointestinal: Denies abdominal pain, vomiting, diarrhea, changes in appetite, dysphagia, pyrosis, flatulence, eructation, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool, pain in flank

Genitourinary : Denies urinary frequency/urgency, incontinence, dysuria, nocturia, oliguria, polyuria, impotence, anorgasmia, sexually transmitted infections, contraception

Musculoskeletal : Denies muscle/joint pain, deformity or swelling, redness, arthritis

Peripheral Vascular : Denies intermittent claudication, coldness, trophic changes, varicose veins, peripheral edema, color changes

Hematologic : Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE

Endocrine : Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Nervous System : Denies seizures, loss consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, loss of strength, change in cognition/mental status/memory, weakness (asymmetric)

Psychiatric : (+)  depression/sadness, Denies suicidal ideation, anxiety, obsessive/compulsive disorder, (+) history of seeing mental health professional

Physical Exam:

HR: 72 beats/min

RR:18 breath/min,

Ht: 66 inches

General: A/O x 4, Pt is wearing handcuffs and appears agitated but cooperative. PT is talking excessively at times but is coherent. PT is well appearing and groomed.

Skin: warm and moist, good turgor, non-icteric, no lesions or rashes

Nails: cap refill <2 secs throughout,

Head:  normocephalic, (+) contusion noted to the LT side of face over the LT maxilla , No other obvious abnormality

Eyes: PERRLA, conjunctiva and cornea clear. No scleral icterus

Nose: Nares normal, septum midline, mucosa normal.

Throat: lips, mucosa and tongue are normal; missing upper and lower teeth, front tooth is loose.

Lungs: Clear to auscultation bilaterally, respirations unlabored, no wheezes/ rales/rhonchi

Cardiovascular: Regular rate and rhythm, S1 and S2 normal, no murmur, rubs or gallop

Abdomen: Soft, non- tender, no guarding or rebound tenderness in all 4 quadrants. No masses. No rigidity.

Extremities: Normal in color, size and temp. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted b/l.

Neuro: Pt alert and oriented to time, place and date. Receptive and expressive abilities intact. Full ROM of extremities. Strength 5/5  bilaterally throughout all extremities.CN 2-12 Intact. Reflexes : 2+ throughout.

Mental Status Exam

Appearance and Behavior: PT is alert and oriented x 3, well appearing and groomed. Pt appears agitated and wearing handcuffs but has normal gait..No tics or abnormal movements PT dressed appropriate to age and weather. No dyskinesias, stares or mask-like facies.

Speech and language: PT is coherent. Able to name items shown, categorize them, follow command. Speech is expressive but sometimes rapid. Overall good tone and fluency.

Mood: Pt denies any suicide ideation. Reports that she has been having difficulty controlling her anger recently. Reports that she has been feeling down and depressed recently because of everything she is dealing with. Denies any changes in her interest in doing things.

Thought Processes/Content: No hallucinations, delusions, phobias.

Insight and Judgement: Patient able to express her problems . Able to understand her diagnoses of bipolar disorder. When asked why she stopped taking the medication, PT stated that she lost it but if was given another prescription, she would try to take since it helped her feel better previously.

Memory and Attention: PT is alert and oriented to name, date, time and location, has good recall, good remote and recent memory.

Higher Cognitive Functions: PT has good cognitive functioning. PT is able to name presidents of large cities, perform simple addition, subtraction, multiplication. Has good abstract thinking, understand similarities between words. Good constructional and new learning ability.

Assessment:

20 y/o AA female, presents to Psych ED with contusion to the LT side of face s/p getting into a fight at school with another girl x 2 hours ago. Pt has hx of feeling depressed, insomnia and problems controlling her mood x 2 months. On physical exam, pt shows no sign of cognitive impairment but is displaying signs of mania, agitation and impaired judgment with hx of fighting, shopping sprees and unprotected sexual relationships with multiple partners. PT was evaluated by a psychiatrist Dr. Z x 1 month ago who dx pt with Bipolar Disorder after pt had a manic episode and fought another girl at school the same day. PT was started on lithium 300 mg TID. PT reported that she had some symptom improvement for 1 week but her symptoms worsened after she stopped taking the medication because she lost the bottle.

Bipolar disorder:

• Run urine HCG
• If urine HCG is negative, start pt on Lithium 300 mg TID and monitor pt in psych ED for signs of improvement (decreased agitation and fluctuations in mood). Can also prescribe Risperidone if minimal improvement with lithium.
• Blood work: CBC, CMP, TSH/thyroid function, urine/blood tox, lithium level
• Monitor serum concentration of lithium- therapeutic range (6 and 1.2 milliequivalents per liter (mEq/L).
• Once pt is stable, refer pt to her psychiatrist/establish care with new psychiatrist for further pharmacological management and psychotherapy.
• Talk to patient about healthy sleeping patterns, practices, suggest melatonin. Refer pt to her psychiatrist for further management.

Alcohol use

• Counsel patient on safe alcohol use.

Differential Diagnoses:

• Bipolar 1 disorder: pt has hx of 2 manic episodes, mood fluctuation, poor judgment, hyper-sexuality, depression, insomnia, 1st degree relative with similar hx of possible bipolar disorder, family member with similar hx.
• Bipolar 2 disorder: hx of manic episode- abnormal/persistent elevated mood, partying, spending money, depression, mood swing. No psychotic features. More likely bipolar 1 since pt has had a previous manic episode and 1 st degree relative.
• Depression Disorder- female, onset during 20’s, hx of depressed mood, insomnia, feeling that her mother is ashamed of her, recent breakup, hx of financial problems.
• Borderline Personality Disorder: hx of unstable, unpredictable mood and affect since pt did get into a fight, poor spending. Hx of substance abuse and increased spending. Fights at school. More hx is needed to assess this personality disorder.
• Histrionic Personality Disorder: Possible attention seeking with purchasing new outfits for parties. Hx of fights at school, yelling at teachers. More hx is needed to assess this personality disorder.

Medication options for Bipolar 1 Disorder

Mood stabilizers:

• Lithium( decreased suicide risk), Valproic acid (Depakene, Depakote), Carbamazepine (Tegretol)

2 nd generation( atypical antipsychotic)

Risperidone, Quetiapine Olanzapine or Ziprasidone

• Effective as monotherapy or as adjunctive therapy to mood stabilizers like lithium.

For acute mania

Antipsychotics (Risperidone or Olanzapine > Haloperidol)

Mood stabilizer( Lithium or Valproic acid)

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Nursing Case Study for Bipolar Disorder

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Kelli is a 20-year-old patient brought to the ER after being reported by neighbors in her apartment complex for disruptive behavior. Law enforcement and emergency medical services were called, and, as a team, decided she needed a higher level of medical care.

The patient says she is” on a break from art college” but works at a local restaurant as a server and occasionally cleans houses as well. She has also sold her paintings and drawings in the past as well. She denies taking any medication. She also says, “I don’t understand why I am here. I was working on my art projects, and I guess I played my music too loud or something. I said I’d come here so I would not be arrested.”

What are some questions that should be included in the initial assessment?

• Ask about drug and alcohol consumption and previous episodes. Make sure she does not intend to harm herself or others. Check to see why the patient does not understand coming to a medical treatment facility (make sure she is lucid). Ask about trauma or accidents.

What interventions do you anticipate being ordered by the provider?

• Obtain old medical charts (there may be a pattern). Screen for drugs and alcohol. Assess for trauma (especially head injury, so neuro checks). Complete a thorough medical history to rule out medical reasons for behavior. Conduct a medical examination including labs (eg. thyroid-stimulating hormone, complete blood count, chemistries)

Kelli’s drug and alcohol tests are negative. Her roommate is now at the bedside and asks to speak to staff privately. She expresses concern that Kelli can be emotional at times as well as going days without sleep then not being able to get out of bed. The nurse returns to further evaluate the patient.

With this new information, what might the nurse ask Kelli?

• Ask about “periods of unusually intense emotion, changes in sleep patterns and activity levels, and uncharacteristic behavior—often without recognizing their likely harmful or undesirable effects” (from NIH). Dig deeper to find if these “episodes” last for long or short periods. Specifically, ask about extreme highs and lows, change in appetite, racing thoughts vs concentration difficulty, risky behaviors (eg gambling, extreme shopping sprees, sexual promiscuity), anxiety, excessive talking, thoughts of death/dying.

Kelli admits to being able to stay awake for what seems like entire weekends without being tired, but that is when she says her creativity is best. When she was attending college and living in the dorms, she says she had lots of friends but worried about what she calls “all the partying.” This is because she liked to “hook up” with strangers because it was fun, but she worries about possible sexually transmitted infections now that she is older. She says she was extremely popular, and her talent was at its peak. But there are times she could not pay attention in class or even get out of bed, so she dropped out of school. Sometimes, she cannot even touch her art supplies, but says she is probably the “most talented artist around.”

What signs and symptoms indicate Kelli may have bipolar disorder?

• Sleep disturbances, cycling between being creative and not being able to concentrate, sexual promiscuity, feelings of grandiosity, loss of pleasure of usual activities

Are there risk factors for this condition?

• The exact cause of bipolar disorder is not clear. The problem may be related to an imbalance of chemicals in the brain such as norepinephrine, serotonin, or dopamine. These chemicals allow cells to communicate with each other and play an essential role in all brain functions, including movement, sensation, memory, and emotions.
• Approximately one to three percent of people worldwide have bipolar disorder. People with a family history of bipolar disorder are at increased risk of developing the condition. Most people develop the first symptoms of bipolar disorder between age 15 to 30 years.

Kelli’s medical records have arrived, and the provider advises nursing staff she has a history of being brought to the ER for similar episodes. The provider says, “This patient is a schizophrenic. We don’t have time for this.”

What is the best response to the provider’s statement?

• As the patient’s advocate, the nurse should advise the provider this is inappropriate. First, it is a disparaging remark. Second, if he means schizophrenic, that is not accurate and as an ER physician should refer the patient for further psychiatric screening and evaluation.
• It is never wrong to stand up to providers or colleagues, but it should be done respectfully and NOT in front of the patient when at all possible.

What should the nurse screen Kelli for at this point?

• Suicidal ideations include whether she has a plan or has attempted suicide in the past. Suicide screening is an ongoing process and not just a few questions at admission. Per UpToDate, “A review estimated that approximately 10 to 15 percent of bipolar patients die by suicide and many studies indicate that the rate of suicide deaths in patients is greater than the rate in the general population.”

How can the nurse address Kelli’s question about help?

• Something like (from uptodate), “Treatment of mania focuses on managing symptoms and keeping you safe. In the early phase of mania (called the acute phase), you may be psychotic (having false, fixed beliefs or hearing voices or seeing things others cannot see or hear). You may not be able to make good decisions and you may be at risk of hurting yourself or others. You may need to be treated in a hospital temporarily, until your medicine begins to work.”
• Also, “Once the worst symptoms of mania or depression are under control, treatment focuses on preventing a recurrence. People who have suffered a manic episode are often advised to continue taking medicine(s) to control bipolar disorder. Although medicines are the treatment of choice for bipolar disorder, counseling and talk therapy also have an important role in treatment. This is especially true after an acute episode has passed. Psychotherapy may include individual counseling as well as education, marital and family therapy, or treatment of alcohol and/or drug abuse. Therapy can help you to stick with your medicine, which can decrease the risk of relapse and the need for hospitalization.”

Kelli is amenable to being held for the state’s required psychological hold. She says she wants to be able to live her life as “normally” as possible. She asks about medications that may be available to help.

What patient education about medications should the nurse provide at this time?

• While it is beyond the scope of the RN to prescribe medications, generalized education on pharmaceutical options is acceptable. Saying something like, “Treatments with medications is recommended for people with bipolar disorder, and studies show starting it early and maintaining it is best.” Point out there may be multiple medications needed and they may need to be changed and/or adjusted for her individual responses.

The nurse knows which medications may be prescribed for long-term management of this condition?

• Mood stabilizers (examples: lithium, valproic acid, divalproex sodium, carbamazepine,and lamotrigine). Antipsychotics. [examples: olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), lurasidone (Latuda) or asenapine (Saphris)] Antidepressants or antidepressant-antipsychotic combo like Symbyax combines the antidepressant fluoxetine and the antipsychotic olanzapine Anti-anxiety medications (example: benzodiazepines)

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View the full transcript, nursing case studies.

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

Nursing Case Studies Introduction

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5 Psychiatric Treatment of Bipolar Disorder: The Case of Janice

• Published: February 2013
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Chapter 5 covers the psychiatric treatment of bipolar disorder, including a case history, key principles, assessment strategy, differential diagnosis, case formulation, treatment planning, nonspecific factors in treatment, potential treatment obstacles, ethical considerations, common mistakes to avoid in treatment, and relapse prevention.

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Bipolar disorder case study

Mood disorders are considered a disease of the XXI century. Nevertheless, psychologists know little about this disease, which makes a case study for bipolar disorder especially relevant today. This mental disorder is characterized by a change of manic and depressive states, mixed states, alternation of euphoria and depression.

Patients with bipolar disorder suffer from more severe mood swings than those with which everybody encounters every day.

Causes of a Bipolar Disorder

Despite numerous studies, scientists have not been able to pinpoint the causes of bipolar disturbance development. For many years, the genetic theory has remained popular, although the principle of inheritance is still not clear. The study of identical twins revealed that if one twin gets bipolar disorder, the second of the twins has a significantly increased chance of getting sick. At the same time, the investigation of the causes of the disease is continuing, because it will allow developing effective methods of prevention and treatment.

There are a lot of bipolar disorder case study examples, the development of which are able to give hope for recovery to thousands of patients around the world. According to modern data, bipolar forms of affective disturbances are more likely to affect men, while monopolar ones are three times more likely to affect women.The structure of the brain can also affect the development of the disease. According to the “ignition hypothesis,” when people genetically predisposed to such a disease experience stress, their threshold of emotional stress is significantly reduced, which causes a spontaneous occurrence of episodes. There is also a theory that abnormal mood swings are associated with the balance of the two neurotransmitters – serotonin and norepinephrine (dopamine disturbances are associated with other psychiatric disorders, psychosis, and schizophrenia).

However, some experts believe that the symptoms of the bipolar spectrum are not an abnormal disturbance of the organism, but only a hypertrophic manifestation of the adaptive function. There is a theory that genes that cause severe affective disorders in certain situations can be useful for survival. The inclination to hide, reduce energy consumption and more sleep, which is characteristic of patients during the depression, may have served as a protective mechanism for human ancestors in difficult times. Weak manifestations of mania could also be an advantage because they give an influx of energy, self-confidence and enhance creativity.Another theory suggests that mania and depression are a kind of mechanism of internal self-regulation, self-defense of a person, which is tormented by fear or great internal contradictions. Deep depression protects and isolates a person from the world, drowning out even the feeling of despair with apathy, and mania allows splashing out latent aggression and coping with fear.

Diagnostic of a Bipolar Disorder

A person suffering from bipolar disturbance can not control his or her mood: at times he or she experiences a powerful energy uplift, which is not always appropriate and which rarely turns out to be productive, and at times he or she suffers from the same causeless decline. In the intervals between phases, patients can feel normal. If this period is prolonged (it can last up to 7 years), the patient sometimes begins to forget that there was an illness in his life.One of the main problems of conducting a case study of bipolar disorder, that the number of phases of this disease and their order is unpredictable. In addition, the disease can manifest only in manic, only in hypo maniacal) or only in depressive phases.

Thus, the results of a case study of bipolar disorder are always very specific, individual and do not allow a researcher to create a complete picture of the development of this disease. Bipolar disorder case study diagnosis is especially difficult at hypo maniacal phase because it is perceived by the patient as a completely innocent flow of energy and an increase in mood. A person feels a spiritual uplift and a belief in one’s abilities. A patient shows a keen interest in a variety of topics; is highly motivated and ready for action. In this period a patient is able to work intensively, without feeling tired, and sleeps less. However, this condition has side effects.

A person becomes too self-confident and may lose the ability to assess the situation sensibly. He easily makes impulsive decisions, takes risks, and makes promises without thinking. Anyway, a person with hypomania is still able to make his activity look more or less normal and does not cause much inconvenience to the society. Analyzing bipolar affective disorder case study, it is possible to conclude that the situation is getting out of control mania stage. A person expresses delusional ideas of greatness or insane projects that one wants to fulfill immediately.

A patient can become irritable or aggressive and make more than strange decisions. The diagnosis depends on the form of this phase. In the presence of manic or mixed (when combined with the symptoms of mania and depressive) episodes “bipolar disorder I” is diagnosed, and if he a patient a history of manifestations of hypomania, it is a “bipolar disorder II.”The second option is considered to be less destructive, although some experts have doubts about this. In either case, the patient will most likely periodically fall into depression.

The most dangerous period from the point of view of suicide is the beginning or end of the depression when the mood has already fallen, and the energy is still enough to take some decisive action.

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Language: English | Chinese

Analysis of Misdiagnosis of Bipolar Disorder in An Outpatient Setting

双相情感障碍在门诊的误诊情况分析.

Bipolar disorder is a mental illness with a high misdiagnosis rate and commonly misdiagnosed as other mental disorders including depression, schizophrenia, anxiety disorders, obsessive-compulsive disorders, and personality disorders, resulting in the mistreatment of clinical symptoms and increasing of recurrent episodes.

To understand the reasons for misdiagnosis of bipolar disorder in an outpatient setting in order to help clinicians more clearly identify the disease and avoid diagnostic errors.

Data from an outpatient clinic included two groups: those with a confirmed diagnosis of bipolar disorder (CD group) and those who were misdiagnosed (i.e. those who did in fact have bipolar disorder but received a different diagnoses and those without bipolar disorder who received a bipolar diagnosis [MD group]). Information between these two groups was compared.

There were a total of 177 cases that met the inclusion criteria for this study. Among them, 136 cases (76.8%) were in the MD group and 41 cases (23.2%) were in the CD group. Patents with depression had the most cases of misdiagnosis (70.6%). The first episode of the patients in the MD group was more likely to be a depressive episode (χ 2 =5.206, p =0.023) and these patients had a greater number of depressive episodes during the course of the disease ( Z =-2.268, p =0.023); the time from the onset of the disease to the first treatment was comparatively short ( Z =-2.612, p =0.009) in the group with misdiagnosis; the time from the onset of disease to a confirmed diagnosis was longer ( Z =-3.685, p <0.001); the overall course of disease was longer ( Z =-3.274, p =0.001); there were more inpatients for treatment (χ 2 =4.539, p =0.033); and hospitalization was more frequent ( Z =-2.164, p =0.031). The group with misdiagnosis had more psychotic symptoms (χ 2 =11.74, p = 0.001); particularly when depression occurred (χ 2 =7.63, p = 0.006), and the incidence of comorbidity was higher (χ 2 =5.23, p =0.022). The HCL-32 rating was lower in the misdiagnosis group ( t =-2.564, p =0.011). There were more patients diagnosed with bipolar and other related disorders in the misdiagnosis group than in the confirmed diagnosis group (11.0% v. 4.9%) and there were more patients in the MD group diagnosed with depressive episodes who had a recent episode (78.7% v. 65.9%).

Conclusions

The rate of misdiagnosis of patients with bipolar receiving outpatient treatment was quite high and they often received a misdiagnosis of depression. In the misdiagnosis group the first episode tended to manifest as a depressive episode. In this group there were also a greater number of depressive episodes over the course of illness, accompanied by more psychotic symptoms and a higher incidence of comorbidity. Moreover, these patients apparently lacked insight into their own mania and hypomania symptoms, resulting in difficulties in early diagnosis, longer time needed to confirm the diagnosis, higher rate of hospitalization, and greater number of hospitalizations.

背景

双相情感障碍是一种高误诊率的精神疾病，常被误诊为抑郁症、精神分裂症、焦虑症、强迫症和人格障碍等精神疾病，导致临床症状不能有效控制，病情呈反复发作趋势，故近年来双相情感障碍的误诊问题越来越引起精神科医生的重视。

目的

了解双相情感障碍在门诊的误诊情况，并分析其误诊原因，指导临床医师加强对双相情感障碍的识别，尽量避免或减少其误诊和漏诊。

方法

纳入专家门诊确诊为双相情感障碍的患者，了解其在门诊的就诊及误诊和漏诊情况，通过比较误诊组（包含漏诊者）和确诊组的临床资料进一步分析导致误诊和漏诊的可能原因。

结果

双相情感障碍在专家门诊就诊患者中占 31.5%。符合本研究入组标准的共有177 例，其中误诊组136 例(76.8%)，确诊组41 例(23.2%)，误诊为抑郁症者最多(70.6%)。误诊组患者首次发作更多的表现为抑郁发作( χ2 =5.206, p =0.023)，并且病程中抑郁发作次数更多( Z =-2.268, p =0.023)；误诊组起病至首次治疗的时间较短( Z =-2.612, p =0.009)、而起病至确诊时间更长 ( Z =-3.685, p <0.001)，总病程更长( Z =-3.274, p =0.001)，并且住院治疗的患者更多( χ2 =4.539, p =0.033)，住院次数也更多( Z =-2.164, p =0.031)；误诊组伴有精神病性症状更多( χ2 =11.74, p =0.001)，尤其抑郁发作时( χ2 =7.63, p =0.006)，共病的发生率更高( χ2 =5.23, p =0.022)；误诊组HCL-32 评分更低( t =-2.564, p =0.011)。误诊组诊断为其他特定的双相及相关障碍的患者较确诊组多(11.0% v. 4.9%)，并且误诊组最近发作情况表现为抑郁发作的 患者较多(78.7% v. 65.9%)。

结论

门诊双相情感障碍患者的误诊率高，常被误诊为抑郁症。误诊组患者首次发作更多的表现为抑郁发作，病程中抑郁发作次数更多，伴有精神病性症状更多，共病的发生率更高，并且患者对自身躁狂或轻躁狂发作情况明显认识不足，导致早期难以明确诊断，确诊所需时间更长，住院比率更高，住院次数更多。临床医生应提高对双相情感障碍的识别，避免或减少双相情感障碍的误诊和漏诊。

1. Background

Misdiagnosis is an incorrect diagnosis. The objectives of making a diagnosis are to determine the nature of a disease and to select targeted treatment so that the condition takes a favorable turn. Therefore, the incorrect, incomprehensive, or untimely diagnosis is considered to be a misdiagnosis. In clinical work, bipolar disorder is usually difficult to diagnose in its early stages, especially when it has an early onset. Hirschfeld and colleagues [ 1 ] reported that the misdiagnosis rate for bipolar disorder could reach as high as 69%. Only 20% of patients with bipolar disorder with a current depressive episode were given a confirmed diagnosis within the first year of treatment. A confirmed diagnosis was typically given 5 to 10 years after the first episode of the disease. [ 2 ] Generally, the disorder was misdiagnosed as major depressive disorder, schizophrenia, anxiety disorder, borderline personality disorder, or substance dependence. [ 3 ] It was most commonly misdiagnosed as major depressive disorder. [ 4 ] Because of psychotic symptoms, 31% of patients with bipolar I disorder were mistakenly diagnosed as having other disorders with obvious psychotic symptoms such as schizophrenia or substance use induced psychotic disorders. [ 5 ] The reason for this may be related to clinical practitioners who believe that Schneider’s first rank symptoms are specific symptoms of schizophrenia. [ 6 ] Patients with bipolar II disorder were usually misdiagnosed as having unipolar depression. [ 7 ] The reason might be related to the disease characteristics of bipolar disorder. When the clinical manifestation of the first episode was depression, the patient was often simply diagnosed as having depressive disorder. [ 6 ] Misdiagnosis also occurs when there are other comorbid disorders making affective symptoms, when there is not sufficient attention paid to medical history, or through overly restrictive use of the diagnostic criteria. Some studies showed that bipolar disorder has high comorbidity [ 8 , 9 ] often combined with alcohol and drug dependence, personality disorder, and all sorts of anxiety disorders. The clinical manifestations of comorbidity often masked or were confused with affective symptoms, thereby causing clinical misdiagnosis.

Currently, there is still a lack of systematic research regarding the identification rate and the diagnostic rate of bipolar disorder and clinicians understanding of bipolar disorder. Therefore, we followed up and analyzed data from patients seen in our psychiatric specialist clinic receving treatment for bipolar disorder in order to further understand the reasons for misdiagnosis.

2.1 Participants

The participants in this study were patients with bipolar disorder that had consecutive consultations in the specialist outpatient clinic of our hospital from March 1 st 2016 to August 31 st 2016. There were a total of 181 cases. After selection, 177 cases were enrolled, including 85 males and 92 females. Range of ages was from 18 to 64 years old. The mean(SD) age was 29.1 (11.5) years old. All participants were in line with the following: (a) meeting diagnostic criteria for bipolar disorder according to DSM-V; (b) at least 2 consultation visits after enrollment into this study; (c) aged 18 to 65 years; (d) did not have severe somatic diseases, mental retardation, mental disorders caused by organic diseases, psychoactive substance or alcohol abuse. We excluded pregnant and lactating women, holdouts and people with incomplete clinical data. The enrolled participants were divided into two groups. The participants who were diagnosed with bipolar disorder in the first visit were regarded as the confirmed diagnosis group. The participants who were not diagnosed with bipolar disorder in the first visit and yet received a bipolar diagnosis in the return visit were regarded as the misdiagnosis group (including patients with missed diagnosis: The diagnosis was depression when the participants only showed depressive episode in the first consultation and there was no confirmed mania or hypomania episodes. The diagnosis was bipolar disorder when mania and hypomania were present in the return visit). There were 41 participants (23.2%) in the confirmed diagnosis group and 136 persons (76.8%) in the misdiagnosis group.

2.2 Study methods

Cross-sectional and retrospective study methods were used. Information were collected by professional psychiatrists. The method of information gathering was a combination of checking medical history and interviews with the patient and at least one immediate family member. The relevant clinical data was recorded in detail. Demographic data and clinical data of all patients with bipolar disorder were collected using a self-compiled questionnaire. Clinical data included the age of first onset, the clinical manifestation of the first episode, the time from the onset to the first consultation, the course of disease, the time from the onset to the confirmed diagnosis, diagnosis and classification, the number of manic depressive episodes, whether there were mixed characteristics to these episodes, whether or not patient was hospitalized for treatment, current clinical manifestation and treatment, whether or not there is a family history of mental illness, history of suicide, psychotic symptoms, and whether the bipolar disorder is rapid cycling or comorbid with another illness. All the enrolled patients were assessed with PHQ-9 and HCL-32 self-rating scales. The demographic data and clinical data of the MD group and CD group were compared.

2.3 Statistical methods

All data were processed using SPSS 17.0 Methods used included t-test, Mann-Whitney test, and chi-square test. A p value of less than 0.05 was considered statistically significant and less than 0.01 was considered highly statistically significant.

3.1 Bipolar disorder consultation and misdiagnosis in an outpatient department

In this study, there were 574 cases of outpatients in the specialist clinic. Among these cases, there were 181 patients with bipolar disorder (31.5%). Of these, 177 cases that met the inclusion criteria. Among the cases, 136 cases had had misdiagnosis and the misdiagnosis rate reached 76.8% (see figure 2 ). The most common misdiagnosis was depression (96 cases, 70.6%) followed by schizophrenia (28 cases, 20.6%) and obsessive compulsive disorder (21 cases, 15.4%); also included were anxiety disorder (9 cases, 6.6%) and personality disorder (2 cases, 1.5%) (see figure 3 ). Among them, 16 patients were misdiagnosed with 2 disorders and 2 patients were misdiagnosed with 3 disorders.

Bipolar disorder consultation in the specialist outpatient clinic

Other diagnoses besides Bipolar given (MD group)

3.2 Comparison of the demographic data between the MD group and CD group (see table 1 )

Comparison of the demographic data between the bipolar disorder misdiagnosis group and confirmed diagnosis group

The difference between the demographic data of the two groups was not statistically significant in any category.

3.3 Comparison of the clinical characteristics between the bipolar disorder MD group and CD group

The age at first episode ( t =-0.059, p =0.953), total number of episodes ( Z = -1.019, p = 0.308), number of manic episodes ( Z = -1.373, p = 0.17), and the PHQ-9 score during depressive episode ( t =1.177, p =0.241) had no statistically significant differences. There was also no difference between the two groups in family history of bipolar disorder.

Patients in the MD group more commonly had depression during their first episode ( χ 2 = 5.206, p = 0.023) and the number of depressive episodes was significantly more during the course of illness ( Z = -2.268, p = 0.023). The time from the onset of illness to first treatment was significantly shorter ( Z =-2.612, p =0.009) in the MD group, the time from the onset of illness to the confirmed diagnosis was longer ( Z =-3.685, p <0.001), the overall course of disease was longer ( Z =-3.274, p =0.001), there were more cases receiving inpatient treatment ( χ 2 =4.539, p =0.033), and hospitalization was more frequent ( Z =-2.164, p =0.031). The MD group had more psychotic symptoms ( χ 2 =11.74, p = 0.001), particularly during depressive episodes ( χ 2 =7.63, p = 0.006), and the incidence of comorbidity was higher ( χ 2 =5.23, p =0.022). The HCL-32 rating was lower in the MD group ( t =-2.564, p =0.011). See table 2 .

Comparison of the clinical characteristics between the bipolar disorder misdiagnosis group and confirmed diagnosis group

3.4 Comparison of diagnosis and pharmacological treatment between the MD group and CD group

There was no statistically significant difference between the two groups in diagnostic classification ( χ 2 =1.417, p =504), but there were more patients diagnosed with other specific bipolar and related disorders in the MD group than in the CD group (11.0% v. 4.9%). In terms of recent episodes and clinical medication, the differences between the 2 groups were not statistically significant ( χ 2 =2.816, p =0.093). However, the patients in the misdiagnosis group that in recent mood episodes presented with depression were more (78.7% v. 65.9%). The ratio of rapid cycling episodes in the two groups ( χ 2 =0.012, p =0.914) and having episodes with mixed features ( χ 2 =0.086, p =0.770) were not statistically significant. See table 3

Comparison of the diagnosis and pharmacological treatment between the bipolar disorder misdiagnosis group and confirmed diagnosis group

* p <0.05

** p <0.01

3.5 Comparison of the number of manic and depressive episodes between the MD and CD groups

There were more depressive episodes than manic episodes reported in both groups. This difference in the MD had high statistical significance ( Z = -9.034, p = 0.001). This difference in the CD group also had statistical significance ( Z = -2.508, p = 0.012). See table 4

Comparison of the manic and depressive episodes between the bipolar disorder misdiagnosis group and confirmed diagnosis group

4. Discussion

4.1 main findings.

The results of this study show that the misdiagnosis rate of bipolar disorder was 76.8%. The misdiagnosis rate is slightly higher than the reported results in studies conducted outside of China. [ 1 ] This could be related to the source of our sample. All the patients selected for this study were from the specialist outpatient department, including a larger number of patients with refractory bipolar disorder and atypical symptoms. Of the 177 patients enrolled, 36 had mixed features, 53 had rapid cycling episodes, 51 had comorbidity with other disorders, and 17 were diagnosed with other specific bipolar and related disorders.

This study shows that bipolar disorder patients are most likely to be misdiagnosed with depression. The misdiagnosis rate is as high as 70.6%. The result shares similarity with other studies. [ 2 , 10 ] The reason may be related to the characteristics of the onset of bipolar disorder itself, especially when the episode of onset is depressive with no mania or hypomania. [ 2 , 11 ] In the entire course of bipolar disorder, there were apparently more depressive episodes than manic or hypomanic episodes. [ 12 ] In particular the patients with bipolar II disorder had a depressive presentation throughout most of their illness, [ 13 ] making the clinical diagnosis even more difficult. In the misdiagnosis group of this study, there were more patients having a depressive episode at onset and the frequency of depressive episodes was apparently higher than the manic episode, thereby prolonging the time for clinical diagnosis and increasing the misdiagnosis rate.

Patients with bipolar disorder are often misdiagnosed as having unipolar depression in many circumstances. The reason is related to clinicians or patients lacking knowledge about manic and hypomanic symptoms. Some research shows that the hypomanic state was often mistaken by clinicians or patients as the signs of improvement or remission of depression and they neglected the risk of the disorder further worsening, resulting in misdiagnosis. [ 14 , 15 ] The results of this study showed that the HCL-32 score of the patients in the MD group was lower, which also confirmed the above views.

The results of this study also showed that 20.6% of the patients with bipolar disorder were misdiagnosed as having schizophrenia. In addition, more than half of the 136 patients in the MD group had psychotic symptoms, so it was clear that the presence of psychotic symptoms increased the risk of being misdiagnosed as having schizophrenia especially during the onset of depression. In other studies, 61.5% of patients with bipolar disorder with psychotic symptoms were misdiagnosed as having other mental disorders at the time of first treatment. Moreover, 45% of the patients showed psychotic symptoms such as hallucinations or delusions during depressive episodes. [ 17 ] Some studies [ 18 ] showed that psychotic symptoms are one of the major risk factors for bipolar disorder in patients with depression. They can even be used as a predictor of whether patients with depression have bipolar disorder.

In this study, 15.4% of patients were misdiagnosed with obsessive-compulsive disorder, 6.6% of them were misdiagnosed with anxiety disorder, and 1.5% of them were misdiagnosed as having a personality disorder. The reason for misdiagnosis may be related to the comorbidity of bipolar disorder. Comorbidity was very common in bipolar disorder. This study showed that 1/3 of the patients in the MD group had comorbidity and it was more than in the CD group. It can be seen that the presence of comorbidity may mask emotional symptoms, leading to an increase in misdiagnosis rate. A meta-analysis [ 8 ] indicated that the incidence of comorbid anxiety disorders with bipolar disorder was 42.7% and comorbid obsessive-compulsive disorder was 10.7%. A systematic review of 64 related articles [ 9 ] indicated that the incidence of bipolar disorder comorbid with obsessive-compulsive disorder was between 11% and 21%. Comorbidity results in complex or atypical clinical symptoms, increases the rate of clinical misdiagnosis, and leads to treatment difficulties.

In terms of diagnosis classification, this study showed that there was no significant statistical difference between the two groups. However, the patients of the MD group diagnosed as other specific bipolar disorder and other related disorder were slightly more than the CD group. This could be one of the reasons for misdiagnosis. Many of the symptoms of the patients in this study were hypomanic or manic yet did not fit the time criteria for bipolar. For example hypomanic symptoms only lasted 2 to 3 days, or the time criteria for a hypomanic episode was met but the criteria for other symptoms were not met. These were harder to identify and diagnose at an early stage. However, this study was carried out in a clinic specializing in affective disorders therefore the staff in this setting may have a higher ability to diagnose this type of bipolar disorder.

4.2 Limitations

This study was a cross-sectional and retrospective study. The clinical data were collected mainly from checking past medical records and interviewing patients and at least one family member regarding history of illness. Although each patient had at least two follow-up visits and was asked carefully about the medical history in order to ensure the integrity of the medical history data, it is not guaranteed that the patients and their family members provided a complete medical history. Patients with a long medical history and recurrent episodes were especially unable to recall the timing and manifestation of each episdoe.

The sample for this study originated from a psychiatric clinic specializing in the diagnosis and treatment of affective disorders. The diagnosis and differential diagnosis in this clinic were more standardized; the compliance of the patients was good; the interruption rate of treatment was low; and the drop-out rate from follow-up visits was low. Therefore this sample should be somewhat conducive to follow-up and research development. However, the source of the sample was relatively narrow in this study as it did not include patients with other diagnoses or in other treatment settings. Moreover, the sample size was limited and the diagnosis and treatment situations of bipolar disorder in the general outpatient service were not covered. Therefore, a wider and larger sample study is needed to further explore the current status of bipolar disorder misdiagnosis in psychiatric outpatient clinics in China.

4.3 Implications

When bipolar disorder is misdiagnosed or missed altogether, symptoms cannot be effectively treated, episodes tend to be recurrent, and rapid cycling episodes are more commonly seen. [ 19 ] The risk of suicide increases, [ 20 ] which in turn increases the need for hospitalization and overall burden of the disease. [ 21 ] This can also explain why the patients in the MD group tended to have a higher rate of hospitalization. Therefore, early diagnosis is conducive to appropriate and timely treatment and is beneficial to the maximum recovery of the patients’ function. The earlier the correct diagnosis and treatment, the greater the chance that the patient will recover.

However, any doctor could make mistakes in cross-sectional diagnosis due to the complexity of the presentation of bipolar disorder. This study looked into the causes of bipolar disorder misdiagnosis and missed diagnosis in the outpatient service in hopes of improving guidance for clinical workers. In order to prevent the misdiagnosis of bipolar disorder, clinicians should conduct comprehensive and in-depth clinical examination, pay full attention to emotional symptoms, identify hypomanic symptoms carefully, search for diagnostic clues for bipolar disorder from the clinical symptoms of depression, ask about whether there were past episodes of hypomania or mania especially during medical history collection, and enhance the identification of bipolar disorder so as to avoid or reduce the misdiagnosis and missed diagnosis of bipolar disorder.

Subsequently, clinicians should try harder to identify psychiatric symptoms and affective symptoms and pay close attention to those depressive patients with psychotic symptoms. At the same time, they should consider that comorbidity with other disorders in bipolar is common. Clinicians should improve the identification of comorbidity and avoid or reduce the misdiagnosis and missed diagnosis of bipolar disorder so as to give timely and standardized treatment to patients with bipolar disorder and improve the short-term and long-term treatment effects and quality of life to the greatest extent.

Flowchart of the study

Hui Shen acquired her bachelor’s degree in clinical medicine at Shanghai Second Medical University in 2003. In the same year she began working at the Shanghai Mental Health Center. She has 13 years of clinical work experience in psychiatry. At present, she is the chief rehabilitation doctor at SMHC. Her research interests are the treatment of schizophrenia and bipolar disorder, as well as the cognitive function and rehabilitation therapy of psychiatric patients.

Funding statement

Shanghai Mental Health Center affiliated to the Shanghai Jiao Tong University project (project code: 2016-YJ-12);

Shanghai Mental Health Center affiliated to the Shanghai Jiao Tong University project (project code: 2014 - YL - 04);

National Key Technology Research and Development Program (project code:2012BAI01B04)

Conflicts of interest statement

The authors declare no conflict of interest related to this manuscript.

Informed consent

Written informed consent was provided by all participants.

Ethical approval

This study was approved by the ethics committee of the Shanghai Mental Health Center affiliated to Shanghai Jiao Tong University.

Copyright permission on work’s translation

I have authorized the article to Shanghai Archives of Psychiatry for translation from Chinese to English. I have confirmed all the information included in this article is correct.

Authors’ contributions

Hui Shen: research design, data analysis, and article writing

Li Zhang: medical history collection, scale evaluation

Chuchen Xu: medical history collection, scale evaluation, and literature review

Meijuan Chen: research guidance

Yiru Fang: research guidance