Diagnosis and Treatment Planning
Contemporary Approaches Used for Assessment and Diagnosis
The Center for Quality Assessment and Improvement in Mental Health relates screening tools used for screening for bipolar disorder to include the 'Mood Disorder Questionnaire' (MDQ); the 'Composite International Diagnostic Interview (CIDI) Bipolar Disorder Screening Scale'; Differential Diagnosis of Bipolar Disorder I & II vs. Major Depressive Disorders; and Obtaining a Family History Through the Use of a Genogram. The MDQ is designed for use as a tool to aid in screening for present and past incidences of mania and hypomania and includes 13 questions related to the symptoms of bipolar disorder in addition to items that assess the clustering of symptoms as well as any functional impairment. (CQAIMH, 2014, paraphrased) The Composite International Diagnostic Interview (CIDI) Bipolar Disorder Screening Scale' can be used to make accurate identification of "both threshold and sub-threshold bipolar disorder." (CQAIMH, 2014, p. 1) Differential Diagnosis of Bipolar Disorder I & II vs. Major Depressive Disorders is a guide that is comprised by questions that relate to factors that are assistive in the differentiation of bipolar disorder from major depressive disorder with questions that address: (1) onset age; (2) previous depressive episode frequency; (3) history of family; (4) suicide attempt history; and (4) previous response to antidepressant treatment; and (5) history of substance abuse. (CQAIMH, 2014, p. 1) Obtaining a family history using a genogram is assistive in screening for and identification of any patterns in the family of major depressive or bipolar disorder as well as enabling "visualization of family relationships in other disease processes." (CQAIMH, 2014, p. 1) Further, the family genogram is assistive in planning for disease prevention. (CQAIMH, 2014, paraphrased) the Mayo Clinic states that diagnosis involves a physical examination, laboratory testing, psychological evaluation and mood charting. (2014, paraphrased) Manic symptoms of bipolar disorder include euphoria of an exaggerated nature, lack of concentration, a great level of energy and little need for sleep, self-esteem that is inflated, thoughts that race, activity levels are intensely increased, irritability and impulsivity as well as judgment that is poor. (University of Maryland Medical Center, 2014, paraphrased) The objectives of treatment for bipolar disorder include such that reduces the severity and the number of the episodes of mania and depression experienced by the individual with bipolar disorder. (NHS, 2014, paraphrased)
II. Application of DSM-5 Diagnosis to a Child and Assessment Measures
The DSM-5 states that characteristic of bipolar disorder are at least one "manic or mixed-manic episode during the patient's lifetime." (Zupanick, 2014, p. 1) Bipolar Disorder is stated to be "cyclic" or "period" in nature and to involve the patient cycling upward into the manic or mixed-manic episode before returning to normal referred to as cycling downward into a depressive mode. Previously Bipolar Disorder was termed as manic-depressive disorder. Bipolar Disorder involves the patient experiencing swings to the manic and depressive poles. The manic episode is of the nature that many times follows what is referred to as a prodrome stated to be a stage that may last only a few days up to a few months and characterized by very mild manic symptoms that are nondistinct in nature. However, this is not always the case since many manic episodes may begin very abruptly. Stated to be symptoms characteristics of mania are such as mood being heightened and flight of ideas as well as pressure of speech, increased energy, decreases in the need for sleep and hyperactivity in the individual. (Zupanick, 2014, paraphrased) It is reported that in acute mania that these behaviors are heightened and may be combined with "delusions and some fragmentation of behavior." (Zupanick, 2014, p. 1) In delirious mania the behaviors may present as "bizarre psychotic symptoms." (Zupanick, 2014, p. 1)
According to the DSM-5, the initiative of making a distinction between bipolar disorder and other disorders it is important to know that the illness's course is the most pertinent factor. There is not another disorder that when not treated is characterized by mood disturbance in episodes that are recurrent and that has practically full restoration to normal functioning in between the episodes. Therefore, when the patient has experienced previous episodes and the history available on the patient is complete...
However, without a full history of the patient these questions are sometimes hard to answer making the diagnosis difficult. Bipolar disorder when presenting with a manic episode can be distinguished from catatonic schizophrenia in that the schizophrenic individual is totally self-absorbed and fails to interact with others regardless of how frenzied the patient's state may be. However, manic patients are compelled to become involved with others and display a great interest to do so. According to the DSM-5 a longitudinal view of the patient is preferred over a cross-sectional assessment of the patient. When a history of the progression of the illness beginning from normal and going past stage 1 hypomania enables a diagnosis that is more certain. Differential diagnosis between schizoaffective disorder and bipolar disorder requires a "precise interval history" since in schizoaffective disorder the psychotic symptoms are persistent between the episodes compared to the free intervals noted in bipolar disorder. Diagnostic difficulty may be experienced in relation to Cyclothymia since its presentation includes historical individual episodes of a discrete nature however, the distinction can be made in knowing that the manic symptoms in cyclothymia are extremely mild. The cyclothymic patient may be presenting with what is an extremely long prodome to bipolar disorder requiring ongoing observation across years to make a revision of the diagnosis should a manic episode occur.
Assessment of the patient will include the patient's appearance at presenting and the patient's behavior. Also considered will be the patient's mood and affect, speech and thought content. The patient's thought process will be assessed and any perceptual disturbances as well as impulse and control and level of cognition and sensorium.
The patient will be administered the Substance Abuse Subtle Screening Inventory (SASSI) used to make identification of individuals who have a high potential of substance use disorders. This patient will be administered the version for adolescents. The Hamilton Depression Rating Scale (HAM-D) will also be administered to test for the patient's severity of depression.
Cultural assessment should consider race, ethnicity, social class, language, and degree of acculturation since culture great impacts the development as well as the patient's reporting of mental disorders. Cultural rating scales may be assistive with this patient. The assessment should be culturally competent and sensitive to the patient's level of comfort in revealing private information with people who are not familiar. There is also a variation among cultures in regards to beliefs about the etiology of mental illness and treatment efficacy. The Cultural Formulation Interview (CFI) offered by the DSM-5 will be utilized in assessing this patient.
Substance Abuse Assessment
A substance use Parent-Guardian of Child Age 6-17 adapted from the NIDA-Modified ASSIST can be utilized in assessing possible substance abuse by the patient. However, since the patient's family has not witnessed any substance use on the part of the patient and the patient refuses to speak on this matter then drug-screening testing should be utilized to ensure that the patient is not using any types of illicit drugs.
III. Treatment Plan
The treatment approach in bipolar disorder involves treating the episodes whether manic, mixed-manic and then treating the depressive episode and at the same time giving consideration to three specific treatment phases including acute, continuation and preventive treatment. It is reported in the DSM-5 that lithium is the best choice of treatment since it is the only medication that has been proven effective for all three treatment phases and in both manic and depressive episodes.
Treatment for acute manic or mixed-manic episode involves the use of a mood stabilizer such as lithium, valproate or carbamazepine or even the use of an antipsychotic such as olanzapine, risperidone, apripiprazole, quietiapine or ziprasodone. As stated already lithium is the first choice since it has a longer history of success however, divalpoex may also be used and is more effective for the mixed-manic episode particularly as divalproex has a rapid loading strategy and patients have been shown to respond in only a few days as compared to responding in one to two weeks with lithium. Carbamazepine is effective but not as effective as lithium and not tolerated as well as lithium. The first choice among antipsychotic medication is that of olanzapine since it is very effective in preventative measures. Milder symptoms may indicate the use of a mood stabilizer alone.
There may be some biological basis for the patient's mental illness in that her mother and brother have exhibited mental illness in the past. In addition, the patient is under a great deal of pressure from her parents to excel in school and therefore the patient's levels of stress are very high. The patient expresses that she is 'expected' to be smart because she is an Asian student and then states…
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