Bipolar Disorder Case Study: Katherine's Diagnosis & Care

Introduction to Bipolar Disorder

Bipolar disorder "is a chronic and recurrent serious mental disorder affecting up to 1% of the general population" (McDougall, 2009). It is often misdiagnosed, particularly in adolescents — a time of life when moodiness is extremely common, and behaviors that might seem unusual in other age groups, such as rapid changes in mood, black-and-white thinking, and unacceptable risk-taking, can appear normal. Bipolar disorder also frequently goes unrecognized and untreated because its symptoms may be mistaken for depression during the depressive phase of the illness, and for a personality disorder or schizophrenia during the manic phase. However, it is critical that the disorder be treated early: "the peak age of onset is during adolescence and early adulthood… outcome studies have shown that up to 20% of adults with bipolar disorder have experienced initial symptoms before the age of 19" (McDougall, 2009).

Katherine's Case Presentation

Katherine was referred to the mental health center of her university by her roommate shortly before the Thanksgiving break, right after midterms. A freshman at a large city university, Katherine had quickly become an integral part of the college community. She made friends easily and was very social and gregarious during freshman orientation. She was often seen drinking at fraternity parties with older students and was always quick to buy her many new friends drinks using a fake ID. According to her roommate, Katherine had also experimented casually with drugs, even though she claimed she had not done so before coming to the university.

Katherine had enrolled in five challenging courses — one more than students typically take at the university. She had done well at first, hardly sleeping and studying long into the night. She would often be talking on her cellphone while simultaneously writing a paper and pacing back and forth. However, her grades began to plummet around Halloween. After being "dumped" by her recent boyfriend, Katherine spent most of her days in bed, skipping classes, and getting up late at night to drink. She had also stopped going to meals. When her roommate questioned her behavior, Katherine — normally friendly and talkative — told her to simply "back off."

At first, the roommate assumed Katherine was simply suffering from a typical heartbreak. However, Katherine soon grew agitated. She wrote long letters to her former boyfriend and his new girlfriend, accusing them of betraying her. She also claimed her professors were "out to get her" and did not understand her ideas. Katherine had increasing trouble settling down to do her work, even though she checked out piles of books from the library. She often spent nights at parties, even as she expressed worry about failing. During one particularly restless night, Katherine voiced suicidal ideation, saying she would kill herself if she failed a class. That was when her roommate contacted the health center.

Interviewing Katherine at the health center revealed irrational thought patterns. Her parents were called in. Interviews with them revealed that Katherine had often exhibited unstable moods throughout her life. "She is the type of person who is always really happy or really sad — everything is black and white," said her mother, though the family had attributed this to the normal emotional turbulence of adolescence. They were troubled that Katherine's roommate — herself a fellow teenager — viewed their daughter's behavior as abnormal. The mental health center referred Katherine to the local hospital's psychiatric ward. A search of her room revealed an unpaid credit card bill of $3,000, spent mostly on clothes and entertainment.

Diagnosis

As noted in the Journal of Family Practice (2007), "patients with mood disorders can experience a widely varying pattern of mood episodes. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), presents criteria for each category of mood episode — i.e., major depressive, manic, mixed, and hypomanic. Diagnosis is not based on the presenting episode alone. Rather, the different types of mood episodes serve as building blocks of information that one uses to arrive at the diagnosis."

Katherine's diagnosis was therefore derived from a pattern of episodes rather than any single symptom in isolation. Consistent with the DSM-IV-TR criteria for Bipolar I Disorder, Most Recent Episode Manic, Katherine's most recent episode exhibited the characteristics of mania in line with bipolar disorder. She had also suffered at least one prior major depressive episode and manic episode, but her mood patterns did not indicate the highly disordered thought patterns associated with schizoaffective disorder. She had also recently experienced a depressive episode characterized by two or more of the following: poor appetite, insomnia and hypersomnia, low energy and fatigue, low self-esteem, poor concentration, difficulty making decisions, feelings of hopelessness — all in notable contrast to the agitated, incessant movement and energy she displayed during her manic phase.

During her manic phase, Katherine showed clear signs of inflated self-esteem or grandiosity, a decreased need for sleep, was more talkative than usual, exhibited racing thoughts and a flight of ideas, and engaged in heightened goal-directed social and academic activity. She also demonstrated "excessive involvement in pleasurable activities that have a high potential for painful consequences," including binge drinking, impulsive shopping, and sexual activity, as described in the DSM-IV-TR criteria.