Posted: May 25th, 2022
Bipolar Case Study Bipolar
Bipolar hypothetical case study: Katherine
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 where moodiness is extremely common, and behavior that might seem unusual in other age groups, such as rapid changes in mood, black and white thinking, and unacceptable risk taking seem normal. Bipolar disorder also often goes unrecognized, misdiagnosed, and untreated because its symptoms may be mistaken for depression, during the depressive phase of the illness, and a personality disorder or schizophrenia during the manic phase. However, it is critical that it be treated early: “the peak age of onset is during adolescence and early adulthoodoutcome studies have shown that up to 20% of adults with bipolar disorder have experienced initial symptoms before the age of 19” (McDougall 2009).
Katherine was referred to the mental health center of her university by her roommate in the period shortly before the university was to have its 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 quickly, 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 some drinks, using a fake ID. According to her roommate, Katherine had experimented casually with drugs, even though she said she had not done so before coming to the university.
Katherine had taken five challenging courses, one more than students usually 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, writing a paper, and pace back and forth as she spoke. However, her grades began to plummet around Halloween, as after getting ‘dumped’ by her recent boyfriend, Katherine spent most of her day in bed, not going to classes, and getting up late at night and drinking. She had stopped going to meals as well. When questioned about her behavior, instead of her usual friendly and talkative self, Katherine told her roommate to simply ‘back off.’
At first, the roommate thought that Katherine was simply suffering the symptoms of a typical heartbreak. However, then Katherine began to grow agitated. She wrote long letters to her former boyfriend and his new girlfriend, accusing them of betraying her. She also said her professors were ‘out to get her’ and did not understand her ideas. Katherine had increasing trouble settling to do her work, even though she took piles of books from the library. She often spent the nights going to parties, although she said she was worried about failing. During a particularly restless night, Katherine expressed suicidal ideation, saying she would kill herself if she failed a class. That was when her roommate called the health center.
Interviewing her at the health center revealed irrational thought patterns. Katherine’s parents were called. Interviews with her concerned parents revealed that Katherine had often exhibited unstable moods. ‘She is the type of person who is always really happy or really sad — everything is black and white,’ said her mother, although they had attributed this to the normal angst of adolescence. They were concerned when Katherine’s roommate, a fellow teen, saw their daughter’s behavior as abnormal. The mental health center referred Katherine to the local hospital psychiatric ward. Her parents came to see her. A search of her room revealed an unpaid credit card bill of $3,000, mostly on new clothes and entertainment.
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[R]), 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 thus derived from a pattern of episodes, not one symptom in isolation. Commensurate with the DMV-IV 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 major depressive episode and manic episode before, but her mood patterns did not indicate the presence of the highly disordered thought patterns of schizoaffective disorder. She has also recently experienced a “depressive episode characterized by the presence, while depressed, of 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, and a lack of energy that stood in notable contrast to her agitated, incessant movement and energy 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, had a lack of need for sleep, was agitated in a manner observable to others, had racing thoughts and a flight of ideas accompanied with goal-directed social and academic activity, and also showed features of involvement in pleasurable activities such as binge drinking, shopping, sexual activities, and other types of “excessive involvement in pleasurable activities that have a high potential for painful consequences” as per the DMV-IV.
Review of issues in care and expert opinions
The willingness of Katherine’s family to be involved speaks well of the potential of her case to have a good outcome. To confirm the diagnosis, her parents were asked to complete a Mood Disorder Questionnaire (MDQ), through which they confirmed Katherine’s rapidly shifting moods throughout her adolescence. Katherine would often be best friends with girls, and then have a falling-out with them. Her school record, though strong, was often characterized by bursts of activity, followed by long periods of ‘mental health days.’
Katherine was prescribed a mood stabilizer, to immediately address her condition and to make her a more active part of her treatment. Her parents were referred to therapists in the area that dealt specifically with managing college students and mental disorders. In treating a bipolar adolescent, it is essential that everyone around that individual get ‘on board’ with their treatment. One of the problems is that mania can feel positive. When confronted with her diagnosis, Katherine said that she enjoyed the increased creativity and goal-directed behavior regarding her school assignments. It was difficult to show the patient that this increased activity was fleeting. “Adherence appears to vary with the age of the patient and duration of illnessClinical experience suggests that a younger patient in a first episode simply wants to get on with life and has particular difficulty accepting the chronicity of the illness” (Sherman 2007, p.3). Additionally, “patient beliefs about the illness and medication are often critical in determining adherence behavior…Some may have the incorrect idea that lithium or Depakote [divalproex] is addicting, for example” (Sherman 2007, p.1).
Finding a correct treatment and medication regime can be difficult. It would have to be determined between the university, Katherine’s professors, and her treatment team, how best to salvage her semester, although with proper treatment, being a full-time undergraduate with managed bipolar disorder is certainly possible.
Recommendations for nursing and own personal growth
Adhering to a schedule to reduce external stimulation that can trigger a manic episode and having understanding treatment staff and a university community is essential in monitoring college students like Katherine with bipolar disorder. Treating the bipolar college student is a joint effort between the community, family, and the student herself. College presents many mood pitfalls that can make things difficult even for a relatively stable adolescent. Having a clear schedule and support system is important for a bipolar teen. Also, managing medication and side effects can be especially tricky, as some can trigger mania, if incorrectly prescribed.
Families should be taught to recognize the signs of an episode in their adolescent. The adolescent him or herself must be capable of self-monitoring and treatment compliance. Finally, the school needs to be aware of the need for accommodation and creating an effective support structure, regarding the student’s scheduling, room assignments, and other requirements for attending the university.
DSM-IV Code: Bipolar. Available from psychnet on March 30, 2009 at http://www.psychnet-uk.com/dsm_iv/dysthymic_cyclothymic_episodes.htm#Manic%20Episode:
McDougall, Tim. (2009). Nursing children and adolescents with bipolar disorder: Assessment, diagnosis, treatment, and management. Journal of Child and Adolescent Psychiatric
Nursing, 22(1), 33-9. Retrieved March 30, 2009, from ProQuest Medical
Library database. (Document ID: 1663483211).
Recognizing and understanding bipolar disorder. (2007). Journal of Family Practice.
FindArticles.com. Retrieved March 30, 2009 at http://findarticles.com/p/articles/mi_m0689/is_11_56/ai_n21106670
Sherman, Carl. (2007, April). Achieving adherence in bipolar disorder. Clinical Psychiatry.
FindArticles.com. Retrieved March 30, 2009 at http://findarticles.com/p/articles/mi_hb4345/is_4_35/ai_n29345472
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