San Pedro College

Graduate School Studies

Department of Psychology

Case no. 05
A CASE REPORT ON
BIPOLAR DISORDERS
(Level A)

A Course Requirement on
Advance Abnormal Psychology
Master of Science in Clinical Psychology

Submitted by:
MICHAEL JOHN P. CANOY, RPm

Submitted to:
DR. ORENCITA V. LOZADA, RP, RGC, CSCLP
Professor

A.Y. 2019-2020
Michael John P. Canoy, RPm MS in Psychology

CLINICAL PROFILE

I. PURPOSE OF EVALUATION
This undertaking was originally meant to screen and assess evidences of
underlying physical, mental, and psychological dysfunctions of the client. This will
provide plausible information that will serve as a basis for full clinical diagnosis, case
management and further therapeutic interventions. This document is endorsed for
educational purposes only and will be submitted as a course requirement for PSY504 -
Advanced Abnormal Psychology in the Graduate School Program of the Psychology
Department of San Pedro College, Davao City.

II. IDENTIFYING INFORMATION

a. Demographic Profile
Name: Not Specified
Age: 24 Years Old
Gender: Female
Educational Attainment: Not Specified
Marital Status: Married
Occupation: Unemployed
Religion: Not Specified
Ethnicity: Not Specified
Husband’s Name: Not Specified
Husband’s Occupation: Law Enforcement Officer

b. Medical History
Medical
The patient smoked 2 or 3 packs of cigarettes per day, drank no alcohol, and
never used marijuana, cocaine, or other illicit substances. She drank 4 caffeinated soft
drinks per day. She took birth control pills and had been generally healthy except for
migraine headaches without aura. She had been moderately successful at treating the
headaches with ibuprofen and rest. Her pregnancy and delivery were uncomplicated, but
 Michael John P. Canoy, RPm MS in Psychology

her headaches had been increasing in frequency and duration since giving birth. Only
since the delivery of the child had she been experiencing these brief, but intense, periods
of depressed mood. She described herself before this time as cheerful and outgoing, and
she had sought no prior treatment for mood or anxiety problems. By contrast, many of
her relatives experienced anxiety and/or depression. Her paternal grandfather was
diagnosed with manic depression and hospitalized in a state mental health facility on 1
occasion. Several other male relatives abused alcohol or cocaine. Her father was an
alcoholic. She described him as mercurial and impulsive, prone to outbursts and violent
behaviors even during extended periods of sobriety.
Psychiatric
There was no reported psychiatric history undergone by the client however,
currently, she is having professional help that might help improve her difficulties and
disturbances.
c. Family Background
Family Dynamics
Relationship Age/Status Occupation Medical History Psychiatric Remarks
History
Father Not Specified Not Specified Not Specified Not Specified Her father was
an alcoholic.
She described
him as
mercurial and
impulsive,
prone to
outbursts and
violent
behaviors even
during extended
periods of
sobriety.
Mother Not Specified Not Specified Not Specified Not Specified Not Specified
Husband Age was not Law There were no There were no Has an ex-wife.
mentioned Enforcement reported medical reported The patient is
Officer history of the psychiatric his second wife.
husband history of the The client
 Michael John P. Canoy, RPm MS in Psychology

husband described her

husband as a
“control freak”
who spent too
much time with
his buddies and
helped little
with parenting
Paternal Age was not Not Specified diagnosed with diagnosed with Not Specified
Grandfather mentioned. manic depression manic
and hospitalized depression and
in a state mental hospitalized in a
health facility on state mental
1 occasion health facility
on 1 occasion
Other relatives Ages were not Not Specified Not Specified Not Specified Many of her
mentioned. relatives
experienced
anxiety and/or
depression

d. Psycho-emotional-social History
The patient had a 9-month-old child (her first) and a 1-year marriage to a law
enforcement officer (her first; his third). Her husband's second wife and a child from that
marriage lived nearby. Her relationship with his ex-wife was problematic, but she had
tried to be helpful and friendly in spite of the expected difficulties. She described her
husband as a “control freak” who spent too much time with his buddies and helped little
with parenting. A prenuptial agreement provided that their house stay in his possession if
the marriage ended for any reason. The patient smoked 2 or 3 packs of cigarettes per day,
drank no alcohol, and never used marijuana, cocaine, or other illicit substances. She
drank 4 caffeinated soft drinks per day. She took birth control pills and had been
generally healthy except for migraine headaches without aura. She had been moderately
Michael John P. Canoy, RPm MS in Psychology

successful at treating the headaches with ibuprofen and rest. Her pregnancy and delivery
were uncomplicated, but her headaches had been increasing in frequency and duration
since giving birth. Only since the delivery of the child had she been experiencing these
brief, but intense, periods of depressed mood. She described herself before this time as
cheerful and outgoing, and she had sought no prior treatment for mood or anxiety
problems. By contrast, many of her relatives experienced anxiety and/or depression. Her
paternal grandfather was diagnosed with manic depression and hospitalized in a state
mental health facility on 1 occasion. Several other male relatives abused alcohol or
cocaine. Her father was an alcoholic. She described him as mercurial and impulsive,
prone to outbursts and violent behaviors even during extended periods of sobriety.

III. REASON FOR REFERRAL

A 24-year-old woman presented with nervousness, headache, and insomnia. She

experienced periods of sadness, often unexplained, as well as difficulty controlling her temper
and dealing with stressful situations. Her sadness would occasionally last as long as a week and,
when present, was intense, occurring all day every day, but she reported that she would then
“bounce back” to her usual self. At times, her sadness would be accompanied by a restless
energy and irritability that precipitated arguments with her husband and his ex-wife, among
others. These periods of restless and boundless energy would then switch abruptly back to a state
of intense, depressed mood. When depressed, she would sleep excessively and tended to overeat.
She would isolate herself, let the housework go, and found it hard to get things done. She was
also particularly sensitive to feelings of rejection by others. These difficulties impair her lifestyle
including her mood, eating and sleeping habits, as well as her ability to manage her daily
activities.

IV. PROBLEMS AND SYMPTOMS

Identifying Data and Presenting Conflict
 Nervousness, headache, and insomnia
 Sadness occasionally lasting a week and, when present, was intense, occurring all
day every day
Michael John P. Canoy, RPm MS in Psychology

 Sadness accompanied by a restless energy and irritability that precipitated

arguments with the client’s husband and his ex-wife
 Presence state of intense, depressed mood
 Would sleep excessively and tended to overeat
 Isolate herself, let the housework go, and found it hard to get things done
 Sensitive to feelings of rejection by others
 Increasing frequency of headaches
 Only since the delivery of the child had she been experiencing these brief, but
intense, periods of depressed mood
 Often tearful and irritable
 Difficulties impair her lifestyle including her mood, eating and sleeping habits, as
well as her ability to manage her daily activities.

V. MENTAL EXAMINATION
The diagnostician in training conducted a Mental Status Examination to Sam and
found out the following based on the data collected:

Appearance
 The client doesn’t look physically unkept nor untidy
 Clothing is also not messy nor dirty
 There is no unusual nor atypical physical characteristics

Behavior
 Posture is not seen as slumped
 There is also no rigidity in his body posture
 His posture doesn’t appear to be atypical nor inappropriate
 In his facial expressions, there is marked anxiety, and fear or apprehension as she
was seen to be nervous
Michael John P. Canoy, RPm MS in Psychology

 There is a marked and repetitive suggestion of depression or sadness with the

client last as long as a week and, when present, was intense, occurring all day
every day
 There is a marked anger and hostility as shown with her difficulty controlling her
temper and dealing with stressful situations.
 There is no seen decreased in variability of expression
 There is a marked inappropriateness and bizarreness in his facial expression since
patient was seen to be animated and dramatic during the interview
 Domineering behavior was not present with the client
 Submissiveness and overly compliant is not present to the client
 Provocative behaviors were not present especially when teasing and playing with
his sister.
 There is also no suspicious behavior shown by the client.
 The client was cooperative

Feeling (affect/mood)
 There is no inappropriateness to client’s thought content
 Euphoria and elation are sometimes present with the client as she was affectively
labile
 There is a marked anger and hostility present with the client as seen in her
difficulty controlling her temper and dealing with stressful situations
 There is a marked anxiety, and fear or apprehension as she was seen to be nervous
losing consciousness; not to be found in time; and might be buried alive.
 There is a marked and repetitive suggestion of depression or sadness with the
client last as long as a week and, when present, was intense, occurring all day
every day

Perception
 Illusions were not present with the client
 There is no presence of Auditory hallucinations with the client
Michael John P. Canoy, RPm MS in Psychology

 There were no experienced visual hallucinations and other hallucination with the
client

Thinking
 There is no impairment in her level of consciousness
 There is a marked impairment with her concentration/attention as she is unable to
finish tasks she ought to do
 There is no impairment in calculation ability with the client
 There is also no impairment in her intelligence
 The client doesn’t show disorientation to person
 She also doesn’t show any disorientation to place
 The client did not show any disorientation to time
 There is no difficulty in acknowledging the presence of psychological disorder
 Blaming others for her circumstances was not present with the client
 There is marked and repetitive impairment in managing the client’s daily living
activities especially in her lifestyle including her mood, eating and sleeping
habits, as well as her ability to manage her daily activities.
 There is no impairment in his ability to make reasonable decisions.
 Impaired immediate recall was not present
 Impairment in recent memory is also not seen
 Impaired remote memory was also not present
 There were no obsessions and compulsions with the client.
 There no signs of phobias shown by the client.
 Depersonalization is not present with the client
 There were also no suicidal and homicidal idealization with the client
 Delusions are not present with the client
 There were also no ideas of reference nor ideas of influence
 The client also doesn’t show disturbance in association of thoughts
 Decreased and increased flow of thoughts were not seen
Michael John P. Canoy, RPm MS in Psychology

Although there were tendencies and other difficulties seen with the client especially in his
hallucinations and delusions, further evaluation and assessments are needed for a more
holistic and definitive diagnosis.

VI. CASE OVERVIEW

A 24-year-old woman, married, presented with nervousness, headache, and insomnia.
She experienced periods of sadness, often unexplained, as well as difficulty controlling her
temper and dealing with stressful situations. Her sadness would occasionally last as long as a
week and, when present, was intense, occurring all day every day, but she reported that she
would then “bounce back” to her usual self. At times, her sadness would be accompanied by a
restless energy and irritability that precipitated arguments with her husband and his ex-wife,
among others. These periods of restless and boundless energy would then switch abruptly back
to a state of intense, depressed mood. When depressed, she would sleep excessively and tended
to overeat. She would isolate herself, let the housework go, and found it hard to get things done.
She was also particularly sensitive to feelings of rejection by others. These difficulties impair her
lifestyle including her mood, eating and sleeping habits, as well as her ability to manage her
daily activities. These impairments and disturbances were sources of considerable concern and
they interfered significantly with her daily activities.

VII. PRELIMINARY DIAGNOSIS

Based on the information provided and thorough evaluation of the data, the
symptoms and history of the client have fully met the criteria of
296.89 [F31.81] Bipolar II Disorder, most curint episode hypomanic, mild severity,
with peripartum onset, in partial remission

Note: The color red indicates that the presented fact(s) is present in the case. The
color green means that it is evident in the case, however, it is not directly stated. The
color blue, on the other hand, means that it is not present in the case but is probable
which will be given a remark “for further observation”
Michael John P. Canoy, RPm MS in Psychology

296.89 [F31.81] Bipolar II Disorder, most curint episode hypomanic, mild severity, with
peripartum onset, in partial remission
DIAGNOSTIC CRITERIA PRESENTED FACTS
For a diagnosis of bipolar II disorder, it is The criteria for criteria for a current or past
necessary to meet the following criteria for a hypomanic episode and the following criteria
current or past hypomanic episode and the for a current or past major depressive episode
following criteria for a current or past major had been met below
depressive episode

Hypomanic Episode
A. A distinct period of abnormally and Her elevated expansive, or irritable mood
persistently elevated, expansive, or occasionally last as long as a week and, when
irritable mood and abnormally and present, was intense, occurring all day every
persistently increased activity or day
energy, lasting at least 4 consecutive
days and present most of the day,
nearly every day.

B. During the period of mood Four (4) of the following symptoms have
disturbance and increased energy and persisted, represent a noticeable change from
activity, three (or more) of the usual behavior, and have been present to a
following symptoms have persisted significant degree:
(four if the mood is only irritable),
represent a noticeable change from
usual behavior, and have been present
to a significant degree:
This symptom was not manifested by the
1. Inflated self-esteem or grandiosity. client however, it is a duty to know its
presence or absence for sure, thus,
recommended for further observation.
She would then rest for 3 or 4 hours and
Michael John P. Canoy, RPm MS in Psychology

2. Decreased need for sleep (e.g., feels awaken with the same pressured desire to “get
rested after only 3 hours of sleep). things done.

She switched topics a number of times, and

3. More talkative than usual or her speech was moderately pressured
pressure to keep talking.
Her response to the first question—“What
4. Flight of ideas or subjective brings you here to see us today?”—lasted 7
experience that thoughts are racing. minutes without interruption.

This symptom was not manifested by the

5. Distractibility (i.e., attention too client however, it is a duty to know its
easily drawn to unimportant or presence or absence for sure, thus,
irrelevant external stimuli), as reported recommended for further observation.
or observed.
She related frenzied activity into the early
6. Increase in goal-directed activity morning hours that was often accompanied by
(either socially, at work or school, or talking with friends on the phone and
sexually) or psychomotor agitation. planning social outings

This symptom was not manifested by the

7. Excessive involvement in activities client however, it is a duty to know its
that have a high potential for painful presence or absence for sure, thus,
consequences (e.g., engaging in recommended for further observation.
unrestrained buying sprees, sexual
indiscretions, or foolish business
investments).
She described herself before this time as
C. The episode is associated with an cheerful and outgoing, and she had sought no
unequivocal change in functioning prior treatment for mood or anxiety problems
that is uncharacteristic of the
Michael John P. Canoy, RPm MS in Psychology

individual when not symptomatic.

D. The disturbance in mood and the There were no notable data that were
change in functioning are observable presented in the case however it is a duty to
by others. know its presence or absence for sure, thus,
recommended for further observation.

E. The episode is not severe enough to Her judgment was not seriously impaired, and
cause marked impairment in social or beyond arguments with her husband and his
occupational functioning or to ex-wife, she was not involved in any self-
necessitate hospitalization. If there are damaging activities.
psychotic features, the episode is, by
definition, manic.
F. The episode is not attributable to the There was no notable usage of substance that
physiological effects of a substance can affect those episodes
(e.g., a drug of abuse, a medication or
other treatment).
Note: A full hypomanic episode that emerges
during antidepressant treatment (e.g.,
medication, electroconvulsive therapy) but
persists at a fully syndromal level beyond the
physiological effect of that treatment is
sufficient evidence for a hypomanie episode
diagnosis. However, caution is indicated so
that one or two symptoms (particularly
increased irritability, edginess, or agitation
following antidepressant use) are not taken as
sufficient for diagnosis of a hypomanie
episode, nor necessarily indicative of a
bipolar diathesis.
Major Depressive Episode
Michael John P. Canoy, RPm MS in Psychology

A. Five (or more) of the following Six (6) of the following symptoms have been
symptoms have been present during present during the same 2-week period and
the same 2-week period and represent represent a change from previous functioning;
a change from previous functioning; at at least one of the symptoms is either (1 )
least one of the symptoms is either (1 ) depressed mood or (2) loss of interest or
depressed mood or (2) loss of interest pleasure
or pleasure. Note: Do not include
symptoms that are clearly attributable
to a medical condition.

1. Depressed mood most of the day, Her sadness would occasionally last as long
nearly every day, as indicated by as a week and, when present, was intense,
either subjective report (e.g., feels sad, occurring all day every day
empty, or hopeless) or observation
made by others (e.g., appears tearful).
(Note: In children and adolescents,
can be irritable mood.)

2. Markedly diminished interest or She would isolate herself

pleasure in all, or almost all, activities
most of the day, nearly every day (as
indicated by either subjective account
or observation).

3. Significant weight loss when not When depressed, she would sleep excessively
dieting or weight gain (e.g., a change and tended to overeat
of more than 5% of body weight in a
month), or decrease or increase in
appetite nearly every day. (Note: In
children, consider failure to make
expected weight gain.)
Michael John P. Canoy, RPm MS in Psychology

4. Insomnia or hypersomnia nearly

every day. To some extents she tends to oversleep and
other times, has insomnia
5. Psychomotor agitation or
retardation nearly every day There were no notable data that were
(observable by others; not merely presented in the case however it is a duty to
subjective feelings of restlessness or know its presence or absence for sure, thus,
being slowed down). recommended for further observation.

6. Fatigue or loss of energy nearly She would let the housework go, and found it
every day. hard to get things done

7. Feelings of worthlessness or She was also particularly sensitive to feelings

excessive or inappropriate guilt of rejection by others
(which may be delusional) nearly
every day (not merely self-reproach or
guilt about being sick).

8. Diminished ability to think or There were no notable data that were

concentrate, or indecisiveness, nearly presented in the case however it is a duty to
every day (either by subjective know its presence or absence for sure, thus,
account or as observed by others). recommended for further observation.

9. Recurrent thoughts of death (not There were no notable data that were
just fear of dying), recurrent suicidal presented in the case however it is a duty to
ideation without a specific plan, a know its presence or absence for sure, thus,
suicide attempt, or a specific plan for recommended for further observation.
committing suicide.

B. The symptoms cause clinically These difficulties impair her lifestyle

Michael John P. Canoy, RPm MS in Psychology

significant distress or impairment in including her mood, eating and sleeping

social, occupational, or other habits, as well as her ability to manage her
important areas of functioning. daily activities.

C. The episode is not attributable to the

physiological effects of a substance or There was no notable usage of substance that
another medical condition. can affect those episodes as well as not
Note: Criteria A-C above constitute a major attributable to another medical condition
depressive episode.
Note: Responses to a significant loss (e.g.,
bereavement, financial ruin, losses from a
natural disaster, a serious medical illness or
disability) may include the feelings of intense
sadness, rumination about the loss, insomnia,
poor appetite, and weight loss noted in
Criterion A, which may resemble a depressive
episode. Although such symptoms may be
understandable or considered appropriate to
the loss, the presence of a major depressive
episode in addition to the normal response to
a significant loss should be carefully
considered. This decision inevitably requires
the exercise of clinical judgment based on the
individual’s history and the cultural norms for
the expression of distress in the context of
loss
Bipolar II Disorder
A. Criteria have been met for at least one The client met the criteria for hypomanic and
hypomanic episode (Criteria A-F depressive episode
under “Hypomanic Episode” above)
and at least one major depressive
 Michael John P. Canoy, RPm MS in Psychology

episode (Criteria A-C under “Major

Depressive Episode” above).

B. There has never been a manic episode. There were no recorded manic episodes

C. The occurrence of the hypomanic Her symptoms are not better explained by
episode(s) and major depressive schizoaffective disorder, schizophrenia,
episode(s) is not better explained by schizophreniform disorder, delusional
schizoaffective disorder, disorder, or other specified or unspecified
schizophrenia, schizophreniform schizophrenia spectrum and other psychotic
disorder, delusional disorder, or other disorder
specified or unspecified schizophrenia
spectrum and other psychotic disorder.

D. The symptoms of depression or the Her difficulties impair her lifestyle including
unpredictability caused by frequent her mood, eating and sleeping habits, as well
alternation between periods of as her ability to manage her daily activities.
depression and hypomania causes
clinically significant distress or
impairment in social, occupational, or
other important areas of functioning.
Justification Fully satisfied. The diagnostic criteria for
296.89 [F31.81] Bipolar II Disorder, most
curint episode hypomanic, mild severity,
with peripartum onset, in partial remission
is fully met.

VIII. DIAGNOSTIC FEATURES

Bipolar II disorder is characterized by a clinical course of recurring mood episodes
consisting of one or more major depressive episodes (Criteria A-C under "Major
Depressive Episode") and at least one hypomanic episode (Criteria A-F under
Michael John P. Canoy, RPm MS in Psychology

"Hypomanic Episode"). Her elevated expansive, or irritable mood occasionally last as

long as a week and, when present, was intense, occurring all day every day

The major depressive episode must last at least 2 weeks, and the hypomanic
episode must last at least 4 days, to meet the diagnostic criteria. During the mood
episode(s), the requisite number of symptoms must be present most of the day, nearly
every day, and represent a noticeable change from usual behavior and functioning. The
client’s symptoms have been present during the same 2-week period and represent a
change from previous functioning; at least one of the symptoms is either (1 ) depressed
mood or (2) loss of interest or pleasure.
The presence of a manic episode during the course of illness precludes the
diagnosis of bipolar II disorder (Criterion B under "Bipolar II Disorder"). Episodes of
substance/medication-induced depressive disorder or substance/medication-induced
bipolar and related disorder (representing the physiological effects of a medication, other
somatic treatments for depression, drugs of abuse, or toxin exposure) or of depressive and
related disorder due to another medical condition or bipolar and related disorder due to
another medical condition do not count toward a diagnosis of bipolar II disorder unless
they persist beyond the physiological effects of the treatment or substance and then meet
duration criteria for an episode. In addition, the episodes must not be better accounted for
by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform
disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum or
other psychotic disorders (Criterion C under "Bipolar II Disorder"). The depressive
episodes or hypomanic fluctuations must cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning (Criterion D
under "Bipolar II Disorder"); however, for hypomanic episodes, this requirement does
not have to be met. A hypomanic episode that causes significant impairment would likely
qualify for the diagnosis of manic episode and, therefore, for a lifetime diagnosis of
bipolar I disorder. The recurrent major depressive episodes are often more frequent and
lengthier than those occurring in bipolar I disorder. Individuals with bipolar II disorder
typically present to a clinician during a major depressive episode and are unlikely to
complain initially of hypomania. Typically, the hypomanic episodes themselves do not
Michael John P. Canoy, RPm MS in Psychology

cause impairment. Instead, the impairment results from the major depressive episodes or
from a persistent pattern of unpredictable mood changes and fluctuating, unreliable
interpersonal or occupational functioning. Individuals with bipolar II disorder may not
view the hypomanic episodes as pathological or disadvantageous, although others may be
troubled by the individual's erratic behavior. Clinical information from other informants,
such as close friends or relatives, is often useful in establishing the diagnosis of bipolar II
disorder.
A hypomanic episode should not be confused with the several days of euthymia and
restored energy or activity that may follow remission of a major depressive episode.
Despite the substantial differences in duration and severity between a manic and
hypomanic episode, bipolar II disorder is not a "milder form" of bipolar I disorder.
Compared with individuals with bipolar I disorder, individuals with bipolar II disorder
have greater chronicity of illness and spend, on average, more time in the depressive
phase of their illness, which can be severe and/ or disabling. Depressive symptoms co-
occurring with a hypomanic episode or hypomanic symptoms co-occurring with a
depressive episode are common in individuals with bipolar Π disorder and are
overrepresented in females, particularly hypomania with mixed features. Individuals
experiencing hypomania with mixed features may not label their symptoms as
hypomania, but instead experience them as depression with increased energy or
irritability.
The client met the criteria for hypomanic and depressive episode There were no
recorded manic episodes. Her symptoms are not better explained by schizoaffective
disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other
specified or unspecified schizophrenia spectrum and other psychotic disorder. Her
difficulties impair her lifestyle including her mood, eating and sleeping habits, as well
as her ability to manage her daily activities. Her symptoms were also not attributable to
any substance-related effect nor effect from another medical condition. Also it is seen
that most days, her depressive episodes were more frequent than her hypomanic
symptoms,
Michael John P. Canoy, RPm MS in Psychology

IX. CONTRIBUTORY AND CAUSAL FACTORS

Although contributory factors and/or causal factors were not fully stipulated in the
case, the diagnostician in training is looking into possibility that these difficulties may
involve the following factors:
Genetic and physiological. The risk of bipolar II disorder tends to be highest
among relatives of individuals with bipolar II disorder, as opposed to individuals with
bipolar I disorder or major depressive disorder. There may be genetic factors influencing
the age at onset for bipolar disorders.
Gender-related. Whereas the gender ratio for bipolar I disorder is equal, findings
on gender differences in bipolar II disorder are mixed, differing by type of sample (i.e.,
registry, community, or clinical) and country of origin. There is little to no evidence of
bipolar gender differences, whereas some, but not all, clinical samples suggest that
bipolar II disorder is more common in females than in males, which may reflect gender
differences in treatment seeking or other factors.

X. ASSOCIATED FEATURES
A common feature of bipolar II disorder is impulsivity, which can contribute to
suicide attempts and substance use disorders. Impulsivity may also stem from a
concurrent personality disorder, substance use disorder, anxiety disorder, another mental
disorder, or a medical condition. There may be heightened levels of creativity in some
individuals with a bipolar disorder. However, that relationship may be nonlinear; that is,
greater lifetime creative accomplishments have been associated with milder forms of
bipolar disorder, and higher creativity has been found in unaffected family members. The
individual's attachment to heightened creativity during hypomanic episodes may
contribute to ambivalence about seeking treatment or undermine adherence to treatment.

XI. ETIOLOGY AND PREVALENCE

Prevalence
Michael John P. Canoy, RPm MS in Psychology

The 12-month prevalence of bipolar II disorder, internationally, is 0.3%. In the United

States, 12-month prevalence is 0.8%. The prevalence rate of pediatric bipolar II disorder
is difficult to establish. DSM-IV bipolar I, bipolar II, and bipolar disorder not otherwise
specified yield a combined prevalence rate of 1.8% in U.S. and non-U.S. community
samples, with higher rates (2.7% inclusive) in youths age 12 years or older.

XII. DEVELOPMENT AND COURSE

Although bipolar II disorder can begin in late adolescence and throughout
adulthood, average age at onset is the mid-20s, which is slightly later than for bipolar I
disorder but earlier than for major depressive disorder. The illness most often begins with
a depressive episode and is not recognized as bipolar II disorder until a hypomanie
episode occurs; this happens in about 12% of individuals with the initial diagnosis of
major depressive disorder. Anxiety, substance use, or eating disorders may also precede
the diagnosis, complicating its detection. Many individuals experience several episodes
of major depression prior to the first recognized hypomanie episode. The number of
lifetime episodes (both hypomanie and major depressive episodes) tends to be higher for
bipolar II disorder than for major depressive disorder or bipolar I disorder. However,
individuals with bipolar I disorder are actually more likely to experience hypomanie
symptoms than are individuals with bipolar II disorder.The interval between mood
episodes in the course of bipolar II disorder tends to decrease as the individual ages.
While the hypomanie episode is the feature that defines bipolar II disorder, depressive
episodes are more enduring and disabling over time. Despite the predominance of
depression, once a hypomanie episode has occurred, the diagnosis becomes bipolar II
disorder and never reverts to major depressive disorder. Approximately 5%-15% of
individuals with bipolar II disorder have multiple (four or more) mood episodes
(hypomanie or major depressive) within the previous 12 months. If
this pattern is present, it is noted by the specifier "with rapid cycling." By
definition, psychotic symptoms do not occur in hypomanie episodes, and they appear to
be less frequent in the major depressive episodes in bipolar II disorder than in those of
bipolar I disorder. Switching from a depressive episode to a manic or hypomanie episode
(with or without mixed features) may occur, both spontaneously and during treatment for
depression. About 5%-15% of individuals with bipolar II disorder will ultimately develop
 Michael John P. Canoy, RPm MS in Psychology

a manic episode, which changes the diagnosis to bipolar I disorder, regardless of

subsequent course. Making the diagnosis in children is often a challenge, especially in
those with irritability and hyperarousal that is nonepisodic (i.e., lacks the well-
demarcated periods of altered mood). Nonepisodic irritability in youth is associated with
an elevated risk for anxiety disorders and major depressive disorder, but not bipolar
disorder, in adulthood. Persistently irritable youths have lower familial rates of bipolar
disorder than do youths who have bipolar disorder. For a hypomanie episode to be
diagnosed, the child's symptoms must exceed what is expected in a given environment
and culture for the child's developmental stage. Compared with adult onset of bipolar II
disorder, childhood or adolescent onset of the disorder may be associated with a more
severe lifetime course. The 3-year incidence rate of first-onset bipolar II disorder in
adults older than 60 years is 0.34%. However, distinguishing individuals older than 60
years with bipolar II disorder by late versus early age at onset does not appear to have
any clinical utility.

XIII. RISK AND PROGNOSTIC FACTORS

Genetic and physiological. The risk of bipolar II disorder tends to be highest among
relatives of individuals with bipolar II disorder, as opposed to individuals with bipolar I
disorder or major depressive disorder. There may be genetic factors influencing the age at
onset for bipolar disorders.

Course modifiers. A rapid-cycling pattern is associated with a poorer prognosis. Return

to previous level of social function for individuals with bipolar II disorder is more likely
for individuals of younger age and with less severe depression, suggesting adverse effects
of prolonged illness on recovery. More education, fewer years of illness, and being
married are independently associated with functional recovery in individuals with bipolar
disorder, even after diagnostic type (I vs. II), current depressive symptoms, and presence
of psychiatric comorbidity are taken into account.

Suicide risk is high in bipolar II disorder. Approximately one-third of individuals with

bipolar II disorder report a lifetime history of suicide attempt. The prevalence rates of
lifetime attempted suicide in bipolar II and bipolar I disorder appear to be similar (32.4%
and 36.3%, respectively). However, the lethality of attempts, as defined by a lower ratio
 Michael John P. Canoy, RPm MS in Psychology

of attempts to completed suicides, may be higher in individuals with bipolar II disorder

compared with individuals with bipolar I disorder. There may be an association between
genetic markers and increased risk for suicidal behavior in individuals with bipolar
disorder, including a 6.5-fold higher risk of suicide among first-degree relatives of
bipolar II probands compared with those with bipolar I disorder.

XIV. DIFFERENTIAL DAGNOSIS

Major depressive disorder. The client’s symptoms of Hypomania and depressive
episodes are better explained by the diagnosis stipulated in the previous sections, thus,
this differential diagnosis is ruled out.

Cyclothymic disorder. There were no are numerous periods of hypo- manic symptoms
and numerous periods of depressive symptoms that do not meet symptom or duration
criteria for a major depressive episode thus, this differential diagnosis is ruled out.

Schizophrenia spectrum and other related psychotic disorders. The client’s

symptoms of Hypomania and depressive episodes are better explained by the diagnosis
stipulated in the previous sections, thus, this differential diagnosis is ruled out.

Panic disorder or other anxiety disorders. Major depressive disorder. The client’s
symptoms of Hypomania and depressive episodes are better explained by the diagnosis
stipulated in the previous sections, thus, this differential diagnosis is ruled out.

Substance use disorders. Her symptoms were also not attributable to any substance-
related effect nor effect from another medical condition.

Attention-deficit/hyperactivity disorder. The client’s symptoms of Hypomania and

depressive episodes are better explained by the diagnosis stipulated in the previous
sections, thus, this differential diagnosis is ruled out.

Personality disorders. The client’s symptoms of Hypomania and depressive episodes

are better explained by the diagnosis stipulated in the previous sections, thus, this
differential diagnosis is ruled out.
 Michael John P. Canoy, RPm MS in Psychology

Other bipolar disorders. There were no mania present with the client and the client’s
symptoms of Hypomania and depressive episodes are better explained by the diagnosis
stipulated in the previous sections, thus, this differential diagnosis is ruled out.

XV. COMORBIDITY
Bipolar II disorder is more often than not associated with one or more co-
occurring mental disorders, with anxiety disorders being the most common.
Approximately 60% of individuals with bipolar II disorder have three or more co-
occurring mental disorders; 75% have an anxiety disorder; and 37% have a substance use
disorder. Children and adolescents with bipolar II disorder have a higher rate of co-
occurring anxiety disorders compared with those with bipolar I disorder, and the anxiety
disorder most often predates the bipolar disorder. Anxiety and substance use disorders
occur in individuals with bipolar II disorder at a higher rate than in the general
population. Approximately 14% of individuals with bipolar II disorder have at least one
lifetime eating disorder, with binge-eating disorder being more common than bulimia
nervosa and anorexia nervosa.
These commonly co-occurring disorders do not seem to follow a course of illness
that is truly independent from that of the bipolar disorder, but rather have strong
associations with mood states. For example, anxiety and eating disorders tend to associate
most with depressive symptoms, and substance use disorders are moderately associated
with manic symptoms.

XVI. TREATMENT PLAN

LONG-TERM GOALS
1. Fall asleep calmly and stay asleep without any undue reassuring parental presence required.
2. Feel refreshed and energetic during waking hours.
3. Reduce overall frequency, intensity, and duration of the anxiety so that daily functioning is not
impaired.
4. Elevate mood and show evidence of usual energy, activities, and socialization level.
5. Renew typical interest in academic achievement, social involvement, and eating patterns as well
as occasional expressions of joy and zest for life.
6. Develop healthy interpersonal relationships that lead to alleviation and help prevent the relapse of
 Michael John P. Canoy, RPm MS in Psychology

depression symptoms
7. Appropriately grieve the loss in order to normalize mood and to return to previous adaptive level
of functioning.

SHORT-TERM GOALS THERAPEUTIC INTERVENTION

State no longer having thoughts of self- harm  Assess and monitor the client’s suicide
potential.
 Arrange for hospitalization, as necessary,
when the client is judged to be harmful to self.
Identify and replace depressive thinking that leads to  Assist the client in developing an awareness
depression. of his / her automatic thoughts that reflect a
depressogenic schemata; challenge depressive
thinking patterns and replace them with
reality- based thoughts
Learn new ways to overcome depression through  Assist the client in developing age appropriate
activity. coping strategies for managing feelings of
depression (e.g., more physical exercise, less
internal focus, increased social involvement,
more assertiveness, greater need sharing,
constructive anger expression); reinforce
success.
 Engage the client in “behavioral activation”
by scheduling activities that have a high
likelihood for pleasure and mastery; use
rehearsal, role-p laying, role reversal as
needed, to assist adoption in the client’s daily
life; reinforce success
Specify what in the past or present life contributes to  Explore the emotional pain from the client’s
sadness past that contributes to the feelings of
hopelessness and low self-esteem
Adjust sleep hours to those typical of the  Monitor the client’s sleep patterns and the
developmental stage restfulness of sleep.
Describe current sleep pattern  Assess the client’s presleep and actual sleep
 Michael John P. Canoy, RPm MS in Psychology

patterns.
 Ask the client and / or parents to keep a
written record of presleep activity, sleep time,
awakening occurrences, and parental
responses to the child; provide a form to chart
data.
 Review the record of the client’s presleep and
sleep activity to assess for overstimulation,
parental reinforcement, and contributing
stressors
Follow a sleep- induction schedule of events  Reinforce the client’s consistent adherence to
a calming sleep induction routine.

XVII. REFERENCES

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Arlington, VA: Author

Jongsma, A. E. Jr. (2014). The Child Psychotherapy Treatment Planner. 5th Edition, 425-434

XVIII. ATTACHMENTS
CASE STUDY

Topic: Bipolar Disorder

A 24-year-old woman presented with nervousness, headache, and insomnia. She

experienced periods of sadness, often unexplained, as well as difficulty controlling her temper
and dealing with stressful situations. Her sadness would occasionally last as long as a week and,
when present, was intense, occurring all day every day, but she reported that she would then
“bounce back” to her usual self. At times, her sadness would be accompanied by a restless
energy and irritability that precipitated arguments with her husband and his ex-wife, among
others. These periods of restless and boundless energy would then switch abruptly back to a state
of intense, depressed mood. When depressed, she would sleep excessively and tended to overeat.
She would isolate herself, let the housework go, and found it hard to get things done. She was
also particularly sensitive to feelings of rejection by others, but her mood could be temporarily
brightened, if she were occupied by activities she enjoyed.
Michael John P. Canoy, RPm MS in Psychology

The patient had a 9-month-old child (her first) and a 1-year marriage to a law enforcement
officer (her first; his third). Her husband's second wife and a child from that marriage lived
nearby. Her relationship with his ex-wife was problematic, but she had tried to be helpful and
friendly in spite of the expected difficulties. She described her husband as a “control freak” who
spent too much time with his buddies and helped little with parenting. A prenuptial agreement
provided that their house stay in his possession if the marriage ended for any reason.
The patient smoked 2 or 3 packs of cigarettes per day, drank no alcohol, and never used
marijuana, cocaine, or other illicit substances. She drank 4 caffeinated soft drinks per day. She
took birth control pills and had been generally healthy except for migraine headaches without
aura. She had been moderately successful at treating the headaches with ibuprofen and rest. Her
pregnancy and delivery were uncomplicated, but her headaches had been increasing in frequency
and duration since giving birth. Only since the delivery of the child had she been experiencing
these brief, but intense, periods of depressed mood. She described herself before this time as
cheerful and outgoing, and she had sought no prior treatment for mood or anxiety problems. By
contrast, many of her relatives experienced anxiety and/or depression. Her paternal grandfather
was diagnosed with manic depression and hospitalized in a state mental health facility on 1
occasion. Several other male relatives abused alcohol or cocaine. Her father was an alcoholic.
She described him as mercurial and impulsive, prone to outbursts and violent behaviors even
during extended periods of sobriety.
At the initial interview, the patient was animated and dramatic. Her response to the first question
—“What brings you here to see us today?”—lasted 7 minutes without interruption. She switched
topics a number of times, and her speech was moderately pressured. She was affectively labile,
alternately laughing and crying. Her mood contained elements of depression and hypomania. She
related frenzied activity into the early morning hours that was often accompanied by talking with
friends on the phone and planning social outings. She would then rest for 3 or 4 hours and
awaken with the same pressured desire to “get things done.” During the day, however, she was
often tearful and irritable. Her judgment was not seriously impaired, and beyond arguments with
her husband and his ex-wife, she was not involved in any self-damaging activities. There were
no impairments in reality testing.