Bipolar disorder: symptoms, diagnosis, and treatment approaches

Client is an African-American male, age 19, diagnosed with Bipolar Disorder 1 (296.89), with mixed and psychotic features. Lability and mood cycles have become more rapid recently. Currently, the client is experiencing an acute but mild manic episode.

Risk Influences

The client has no significant biological issues. As the first in his family known to have Bipolar Disorder, no genetic component to the disorder has been determined, but further work in a family therapy context might help determine if there are any biological risk factors. The client is physically healthy. He does not use drugs or alcohol, but tends towards a pattern of excessive denial.

Psychologically, the client struggles with low self-esteem, denial, and mood swings. Although the client reports strong and amicable relationships with family and friends, there may be little empathy from his closest relatives due to perceived stigma about bipolar disorder and lack of knowledge of the disorder and how it can be treated. The client has low self-esteem in general, remains highly critical of himself both in his internal monologue and in the way he speaks about himself to others. Because the client did not graduate high school, he has an especially low view of his intellect and future prospects, even though he has strong communication skills and apparent problem solving skills. The client works at a restaurant on variable shifts, and therefore his sleeping patterns are irregular, exacerbating the symptoms of bipolar disorder and preventing the emergence of a healthy daily routine.

The client has a history of trauma, having witnessed his uncle murder his aunt and two cousins. He remains hypersensitive since this event, and carries a gun. The client has exhibited transient psychotic episodes, as well as manic and depressed cycles and mood lability, the hallmarks of the disorder. Although he reports strong relationships with parents and friends, he reports "constantly fighting" with his girlfriend.

It is possible that denial of his symptoms may have led to the client never having been evaluated for anxiety, depression, or any other mood disorder soon after the traumatic experience. It is also likely that the client's parents, although emotionally supportive, have enabled his denial. Yet the client may also have been misdiagnosed or his symptoms unrecognized due to lack of awareness of the disorder or gender bias in psychiatric evaluations. According to the Depression and Bipolar Support Alliance (DBSA, 2015), both women and men are often misdiagnosed with men more likely to be misdiagnosed with schizophrenia.

Protective Influences

Although there are some risk factors associated with being the only person in his family to be diagnosed with bipolar disorder, this gives the client the opportunity to view the disorder as something he can control, rather than something that is innately "wrong" with him, or that he cannot change because of his genes. Also, the client's recovery could help other relatives who might have shown signs of the disorder but never knew how to recognize it or whether to seek attention. The client could become a positive influence on family members, which is highly likely given that the client reports being close with his parents. He also notes that when he is socializing with his friends, he experiences much less mood lability and especially less depression. The client has no substance abuse history.

The client generally has strong social skills. The client also has strong problem solving abilities and communication skills. He has a knack for controlling his emotions, which he claims is a learned behavior. Because of this, the client has been responding well to cognitive behavioral therapy. Currently, the client is focused on developing a stronger daily routine and hopes to finish school and prepare for a career. Recently, the client's tendency towards denial has been subsiding and the client seems motivated for treatment and positive about future outcomes. The support of his parents has been tremendously helpful in encouraging the client to seek help and improve his self-esteem.

Bipolar Disorder Overview

Bipolar disorder is characterized by intense swings in mood that impede functioning in daily life. The term "bipolar" refers to the two poles of mania and depression, between which the person will swing. Manic periods may be experienced as having high energy, and can be experienced as extreme elation or as extreme irritability. One of the reasons why bipolar disorder can go unrecognized for long periods of time is the fact that some of its features seem like typical mood swings, or the manic episodes may be misconstrued as anger or irritability. Depressive periods can lead to suicidal ideation or even to suicide attempts. Bipolar disorder is sometimes referred to as manic depression. It is a serious mental illness, not only because of the client's potential for suicide but also because of the way bipolar disorder impacts quality of life and ability to cope with day-to-day activities. Clients vary in terms of how long they may remain at one pole or another, or how rapid the cycling occurs. This client has been recently diagnosed, but claims that lately the cycling has been more rapid than in the past.

The median age of onset for bipolar disorder is 25 years, with a lower median age of onset for men versus women (CDC, 2015). The disorder does not disproportionately affect any one ethnic group. Although this client does not have a formal history of diagnosis in the family, research has shown a genetic component may be a factor in the etiology of bipolar disorder (DBSA, 2015). Bipolar disorder affects a fairly large number of people. Almost 6 million Americans (2.6% of the population) are affected by bipolar disorder each year (DBSA, 2015). Unfortunately, many clients suffer without a formal diagnosis for "up to ten years ... before getting an accurate diagnosis, with only one in four receiving an accurate diagnosis in less than three years," (DBSA, 2015). Reasons for delayed diagnosis is that disorder is often difficult to diagnose, and many clients are misdiagnosed with presenting symptoms of disorders with some similar symptom sets such as depression, psychoses, or schizophrenia. Early detection is a major protective factor in the recovery process for bipolar disorder.

This client has suffered a trauma in the past, which may have caused precipitating disorders including anxiety or post-traumatic stress disorder. However, the current diagnosis of Bipolar Disorder 1 accurately reflects the core set of symptoms and the length of time the client has expressed those symptoms, in accordance with the DSM-V.

Bipolar disorder frequently occurs with other mood disorders, particularly anxiety disorders. In fact, Johnson, Cohen & Brook (2000) found "adolescents with anxiety disorders may be at increased risk for bipolar disorder or clinically significant manic symptoms during early adulthood," which may suggest that the client might have been diagnosed with an anxiety disorder or post-traumatic stress disorder after witnessing his aunt and cousins die (p. 1679). Johnson, Cohen & Brook (2000) also found that "adolescents with manic symptoms may be at increased risk for anxiety and depressive disorders during early adulthood," making treatment interventions critical for the client (p. 1679).

Treatment outcomes are more likely to be successful when patients are compliant, but also when the patient exhibits shorter durations of the illness (Keck, et al., 1998). Keck et al. (1998) also found that social class is correlated with treatment outcomes, with higher socio-economic class linked to more positive outcomes. The most important factor in ensuring treatment success seems to be early intervention, because delayed diagnosis or delayed administration of pharmaceuticals are linked with higher rates of suicide, higher comorbidities, higher rates of hospitalization, and worsened psychosocial functioning (Balanza-Martinez, Lacruz & Tabares-Seisdedos, 2015). A related issue in the staging of recovery is client satisfaction with the treatment. Clients who are more satisfied with their treatments are more compliant and therefore have a more "positive outlook about their illness and their ability to cope with it," (DBSA, 2015). Therefore, it is important to discover a range of flexible treatment options with the client. Client-focused therapy also takes into account the need for the maintenance of strong social supports, one of the client's main protective factors.

Evidence-Based Treatments

Cognitive behavioral therapy (CBT) is recommended because it has been shown to especially reduce the pattern of denial in clients with Bipolar Disorder (Parikh, et al., 2013). However, CBT should be supplemented with talk therapy and pharmacological interventions because CBT alone does not necessarily lead to improved outcomes (Parikh, et al., 2013). CBT can help clients evolve their own coping mechanisms that are adaptive especially for manic episodes and can also help the client with other issues including his desire to improve his job prospects, improve his relationship with his girlfriend, and return to school (Parikh, et al., 2013). CBT may be particularly helpful when combined with other psychosocial treatment interventions including psychoeducation.

Medications available to the client include lithium, carbamezpine, divalproex, risperidone, olanzapine, quetiapine, ziprasidone, lamotrigine, and aripiprazole. Lithium remains one of the most common pharmaceutical mood stabilizers, and has continually proven its effectiveness in alleviating many of the more serious symptoms of bipolar disorder. For example, lithium has been effective in preventing self-harm and reducing rates of successful suicide in patients with mood disorders (Cipriani, et al., 2005). Lithium has also proven effective in reducing relapse during long-term recovery and can be considered part of an overall maintenance medication (Geddes & Miklowitz, 2013). Yet recent research has revealed that lithium may not lead to sustained symptom relief in the majority of clients and that an optimal personalized treatment plan should not rely on lithium for symptom management and mental health maintenance (Nierenberg, 2013). Anti-psychotic medications like quetiapine may be indicated for temporary use, particularly during psychotic breaks or manic episodes (Geddes & Miklowitz, 2013). The anti-convulsant drugs like lamotrigine and divalproex may be less effective for the client and are not recommended at this time (Geddes & Miklowitz, 2013).

Research has shown that clients with bipolar disorder tend to experience major depressive episodes "more than three times as frequently as symptoms of severe mood elevation or mania," ("Questions and Answers About the STEP-BD Acute Depression Medication Trial," 2007). Because of the fact that patients with bipolar disorder cannot be treated as if they were clients with mono-polar depression, using medications to help the client cope during these difficult depressive episodes can be tricky. Antidepressants are usually not recommended for people with bipolar disorder because they can easily trigger mania and "might actually worsen the course" of the illness ("Questions and Answers About the STEP-BD Acute Depression Medication Trial," 2007).

A course of treatment that is flexible and adaptable is strongly recommended for this client. Geddes & Miklowitz (2013) found that at different stages of the illness, it may be necessary to utilize different combinations of medications and/or psychotherapeutic interventions. The National Institute of Mental Health (2007) issued a press release claiming that patients who take medications for bipolar disorder have more rapid rates of recovery and longer periods of recovery with fewer remissions when their medications are combined with intensive psychotherapy. Brief forms of psychotherapy to target specific client needs such as career development and life coaching, or relationship counseling with his girlfriend, could be helpful periodically. Targeting the issues specific to the client's bipolar symptoms, both mania and depression, will require more intensive psychotherapy. Three of the most efficacious types of intensive psychotherapies for bipolar particularly include cognitive behavioral therapy, family-focused therapy, and interpersonal and social rhythm therapy (National Institute of Mental Health, 2007). This client is likely to benefit from all three of these types of intensive psychotherapies at different stages of his recovery.