Bipolar Disorder I: Case Study, Risk Factors, and Treatment

Client Overview and Diagnosis

The client is an African-American male, age 19, diagnosed with Bipolar Disorder I (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 risk factors. 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 whether any biological risk factors exist. The client is physically healthy and does not use drugs or alcohol, though he tends toward a pattern of excessive denial.

Psychologically, the client struggles with low self-esteem, denial, and mood swings. Although he 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 a lack of knowledge about the disorder and how it can be treated. The client remains highly critical of himself, both in his internal monologue and in the way he speaks about himself to others. Because he did not graduate high school, he holds an especially low view of his intellect and future prospects, even though he demonstrates strong communication and apparent problem-solving skills. The client works at a restaurant on variable shifts, resulting in irregular sleeping patterns that exacerbate the symptoms of bipolar disorder and prevent 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 depressive cycles and mood lability — the hallmarks of the disorder. Although he reports strong relationships with his 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 in the period following the traumatic experience. It is also likely that his parents, although emotionally supportive, have enabled his denial. 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 risk factors associated with being the only person in his family diagnosed with bipolar disorder, this distinction also gives the client the opportunity to view the disorder as something he can manage, rather than something innately "wrong" with him or unchangeable because of genetics. The client's recovery could also help other relatives who may have shown signs of the disorder but never knew how to recognize or address it. He could become a positive influence on family members — a role that is highly plausible given that the client reports being close with his parents. He also notes that when socializing with friends, he experiences much less mood lability and especially less depression. The client has no history of substance abuse.

The client generally demonstrates strong social skills, problem-solving abilities, and communication skills. He has a knack for controlling his emotions, which he identifies as a learned behavior. Because of this, the client has been responding well to cognitive behavioral therapy. He is currently focused on developing a stronger daily routine and hopes to finish school and pursue a career. Recently, his tendency toward denial has been subsiding, and the client appears motivated for treatment and optimistic about future outcomes. The support of his parents has been tremendously helpful in encouraging him 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 a person will cycle. Manic periods may be experienced as high energy and can manifest as extreme elation or extreme irritability. One reason why bipolar disorder can go unrecognized for extended periods is that some of its features resemble typical mood swings, or manic episodes may be misconstrued as anger or irritability. Depressive periods can lead to suicidal ideation or even suicide attempts. Bipolar disorder is sometimes referred to as manic depression and is a serious mental illness — not only because of the potential for suicide, but also because of the way it impacts quality of life and the ability to cope with day-to-day activities. Clients vary in terms of how long they remain at one pole or how rapidly cycling occurs. This client was recently diagnosed and reports that cycling has become 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 than for women (CDC, 2015). The disorder does not disproportionately affect any one ethnic group. Although this client does not have a formal family history of diagnosis, research has shown that a genetic component may be a factor in the etiology of bipolar disorder (DBSA, 2015). Bipolar disorder affects a substantial number of people: almost 6 million Americans (2.6% of the population) are affected 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 include the disorder's inherent diagnostic difficulty and the tendency for clients to be misdiagnosed with conditions sharing similar symptom sets, such as depression, psychosis, or schizophrenia. Early detection is a major protective factor in the recovery process.

This client suffered a trauma in the past that may have precipitated conditions including anxiety or post-traumatic stress disorder. However, the current diagnosis of Bipolar Disorder I accurately reflects the core set of symptoms and the duration for which those symptoms have been expressed, in accordance with the DSM-5.

Bipolar disorder frequently co-occurs with other mood disorders, particularly anxiety disorders. Johnson, Cohen, and Brook (2000) found that "adolescents with anxiety disorders may be at increased risk for bipolar disorder or clinically significant manic symptoms during early adulthood," suggesting the client may have developed an anxiety or post-traumatic stress disorder after witnessing the deaths of his aunt and cousins (p. 1679). Johnson et al. (2000) also found that "adolescents with manic symptoms may be at increased risk for anxiety and depressive disorders during early adulthood," making timely treatment interventions critical for this client (p. 1679).

Treatment outcomes are more likely to be successful when patients are compliant and when the duration of illness is shorter (Keck et al., 1998). Keck et al. (1998) also found that social class is correlated with treatment outcomes, with higher socioeconomic status linked to more positive results. The most important factor in ensuring treatment success appears to be early intervention, as delayed diagnosis or delayed administration of pharmaceuticals are associated with higher rates of suicide, greater comorbidities, higher rates of hospitalization, and worsened psychosocial functioning (Balanza-Martinez, Lacruz, & Tabares-Seisdedos, 2015). Client satisfaction with treatment is also a key staging factor: clients who are more satisfied with their treatments tend to be more compliant and therefore have a more "positive outlook about their illness and their ability to cope with it" (DBSA, 2015). It is therefore important to identify a range of flexible treatment options in collaboration with the client. Client-focused therapy also accounts for the importance of maintaining strong social supports, one of this client's primary protective factors.

Conclusion and Recovery Outcomes

Wellness or recovery is difficult to measure in persons with bipolar disorder, but it can be tremendously helpful to identify reliable assessment methods that reveal which treatments are most effective for the client. A standard benchmark is not unrealistic; for example, expecting the client to be symptom-free is reasonable in certain contexts. However, a practical gauge of wellness for this client would be experiencing no more than two manic or two depressive episodes over the course of an eight-week period ("Questions and Answers About the STEP-BD Acute Depression Medication Trial," 2007). For this client, assessment would also encompass progress in his outlook on life and self-esteem, advancement in his career and education, and improvements in his relationships.

References

Balanza-Martinez, V., Lacruz, M., & Tabares-Seisdedos, R. (2015). Staging and early intervention in bipolar disorder. Chapter 15 in Neuroprogression and Staging in Bipolar Disorder. Oxford University Press.

CDC (2015). Burden of mental illness. Retrieved from

Cipriani, A., et al. (2005). Lithium in the prevention of suicidal behavior. The American Journal of Psychiatry, 162(10), 1805–1819.

Depression and Bipolar Support Alliance (DBSA, 2015). Bipolar disorder statistics. Retrieved from

Geddes, J. R., & Miklowitz, D. J. (2013). Treatment of bipolar disorder. The Lancet, 381(9878), 1672–1682.

Johnson, J. G., Cohen, P., & Brook, J. S. (2000). Associations between bipolar disorder and other psychiatric disorders during adolescence and early adulthood. The American Journal of Psychiatry, 157(10), 1679–1681.

Keck, P. E., et al. (1998). 12-month outcome of patients with bipolar disorder following hospitalization for a manic or mixed episode. American Journal of Psychiatry, 155(5), 646–652.

National Institute of Mental Health (2007). Intensive psychotherapy more effective than brief therapy for treating bipolar depression. Retrieved from http://www.nimh.nih.gov/news/science-news/2007/intensive-psychotherapy-more-effective-than-brief-therapy-for-treating-bipolar-depression.shtml

Nierenberg, A. A., et al. (2013). Lithium Treatment Moderate-Dose Use Study (LiTMUS) for bipolar disorder. The American Journal of Psychiatry, 170(1), 102–110.

Parikh, S. V., et al. (2013). Psychosocial interventions for bipolar disorder and coping style modification. Canadian Journal of Psychiatry, 58(8), 482–486.

"Questions and Answers About the STEP-BD Acute Depression Medication Trial." (2007). National Institute of Mental Health. Retrieved from http://www.nimh.nih.gov/funding/clinical-research/practical/step-bd/questions-and-answers-about-the-step-bd-acute-depression-medication-trial.shtml