Case Study: Bipolar Disorder in an Adolescent

¶ … bipolar diagnosis: A case study of Miranda

Miranda is a sixteen-year-old second-generation Chinese-American girl who is suspected of manifesting bipolar disorder, according her referencing pediatrician. Miranda's specific, proposed diagnosis according to Appendix D of the DSM is "Bipolar 2 Disorder, in which the primary symptom presentation is recurrent depression accompanied by hypomanic episodes (a milder state of mania in which the symptoms are not severe enough to cause marked impairment in social or occupational functioning or need for hospitalization, but are sufficient to be observable by others)." However, there are also some indications that drug use may be provoking her symptoms Miranda comes from a very high-achieving family that places considerable weight upon academic success. Throughout most of her scholastic life, Miranda has excelled in school but her sophomore year of high school her grades began to decline. According to Miranda's mother (who is a self-described 'stay at home mom'), her daughter's work habits became increasingly erratic.

Sometimes Miranda would stay up all night ostensibly doing homework but would be really talking with her friends on her computer. When confronted by her father about this behavior, Miranda cheerfully told him that she could study in between classes in school and seemed unperturbed by his anger. Miranda, even when she seemed to be working hard and chattered on about her extravagant plans to go to an Ivy League school would have little to show for her efforts working at night. Other days Miranda would say she was so tired she couldn't possibly go to school and lost all interest in her extracurricular activities such as music. Her teachers described her as either overly talkative and 'social' and distracted in class or extremely tired to the point of falling asleep during lectures.

Miranda is described as having a high IQ, particularly in math, but also as being a very sensitive child. However, she has always had many friends and was well-liked at school until recently. Miranda has a self-admitted perfectionist streak and tends to see things in black and white -- either she is a success or a failure, in her estimation. However, as her mood swings became more erratic, she began to lose some of her closest friends. Miranda began to hang out with an uncharacteristically 'cooler' crowd and stay out late in defiance of her curfew which she had never done before. Her mother does not like Miranda's new boyfriend, who she says she suspects of doing drugs. Miranda has begun to wear all-black clothing and her mother is worried that she is going down a bad path.

Miranda's apparent rebellion is all the more inexplicable to her mother and father because both are immigrants from China from whom a profound level of obedience was expected when they were growing up. They describe themselves as holding Miranda to similar standards and have always sought to ensure that their child upholds the tenants of their culture. Although not extremely religious, both parents describe their worldview as coming from a Confucian tradition which stresses obedience from children and a profound respect for parental authority. They find it shocking and disturbing that their child is not honoring this perspective in her actions and is acting in a manner they consider defiant and ungrateful to all they have sacrificed for her. They also state that Miranda's behavior is causing considerable friction between the two of them and is having a negative impact upon their marriage. Regarding the family's mental health history, Miranda's mother was once diagnosed with depression after Miranda's grandmother died and took antidepressants for a brief period of time but both parents say that they do not place much stock in therapy and believe that Miranda is just 'acting out' rather than has a mental disorder.

When asked how she perceives this behavior Miranda says that her parents have always been overly protective and have stifled her creativity. Miranda points to the fact that her older brother was a disappointment to the family (he never finished college) and says that she has been subjected to additional pressure to achieve. Her brother is described as 'lazy' by the parents, often sleeping late and hanging out with a 'bad crowd' as a teenager. Miranda refuses to talk about her relationship with her boyfriend or answer questions about substance abuse, even in private. She says that her parents hold her to a different standards than those of her other friends and attributes her poorer grades to her teacher's unfairness and prejudice against her. "Just because I'm an Asian girl they expect me to be smarter than everyone else. Well, I'm not smart, I can't help it."

To evaluate the mental health of Miranda requires several cultural factors to be taken into consideration when contextualizing her situation. Given their first-generation immigrant status, Miranda's parents may be more likely to interpret their daughter's behavior as disobedience and defiance rather than a mental health issue, given that viewing such actions through a psychoanalytic lens is not part of their tradition. However, the fact that both Miranda's mother and brother have shown signs of mental illness in the past indicates that Miranda's issues may have a biological basis. Her parents are not receptive to the idea of treating their daughter with medications for a psychological condition despite the fact that most mental health practitioners concur that some form of pharmaceutical treatment is necessary in addressing the needs of patients exhibiting bipolarity, which is the diagnosis suggested by Miranda's pediatrician (Duffy et al. 1998). Should the evaluative process indeed result in a bipolar diagnosis, ensuring that Miranda receives appropriate psychopharmacological intervention may prove challenging, given her parents are even somewhat reluctant to allow that there may be a need for therapeutic counseling. But it is also possible that Miranda's symptoms may be linked to using drugs although Miranda has never admitted to using any form of illegal substance or alcohol.

Because of Miranda's age, there are concerns that normal adolescent rebellion may be interpreted as a mental illness. It is not unusual for adolescents to experience a search for identity at Miranda's age within American culture. Because Miranda's parents grew up in China, they may be uncomfortable with the extreme individualism tolerated by American culture. In America it is considered normal for teens to engage in a certain amount of limit-testing that may not be acceptable in other cultures. Additionally, mental illness as a whole is more stigmatized in Chinese culture, which may make Miranda's parents more reluctant to acknowledge that their daughter may have a mental health issue and are more eager to view her issues as self-willed (Alonso et al. 2008, cited by Unite for Sight website).