MULTI-AXIAL DIAGNOSIS

Axis I:

Bipolar I Disorder

Bipolar I disorder is the diagnosis given to an individual who is experiencing, or

has experienced, afull syndrome of manic or mixed symptoms. Theclient may

also have experienced episodes of depression.This diagnosis is further specified

by the currentor most recent behavioral episode experienced. For example, the

specifier might be “single manicepisode” (to describe individuals having a first

episode of mania). For individuals who have hadrecurrent mood episodes, the

current (or most recent) episode may be identified as manic, hypomanic, mixed,

or depressed which is also manifested by Ms. Red.

Diagnostic Criteria for Bipolar I Disorder

A. A distinct period of abnormally and persistently elevated, expansive, or

irritable mood, lasting 1 week (or any duration ifhospitalization is necessary).

Justification: During NPI (April 2, 2017), patient verbalized that sheexperienced

elevated, expansive, or irritable mood for 4 days until 1 week or more and then

she becomes okay after she took up her medicines.

B. During the period of mood disturbance, three (or more) of the following

symptoms have persisted (four if the mood is only irritable) and have been

present to a significant degree:

1. Inflated self-esteem or grandiosity

2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

3. More talkative than usual or pressure to keep talking

4. Flight of ideas or subjective experience that thoughts are racing

5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant

external stimuli)

6. Increase in goal-directed activity (either socially, at work or school, or sexually)

or psychomotor agitation

7. Excessive involvement in pleasurable activities that have a high potential for

painful consequences (e.g., engaging in unrestrainedbuying sprees, sexual

indiscretions, or foolish business investments)

Justification: Through observations, Ms. Red is observed to become more

talkative than usual. She also has a flight of ideas and she claimed that she

unstoppable whenever she is hyperactive. She also claimed that when she is

hyperactive she can memorize easily. She was also easily distracted with other

stimuli around the room during interview.

C. The mood disturbance is sufficiently severe to cause marked impairment in

occupational functioning or in usual social activities or relationships with others,

or to necessitate hospitalization to prevent harm to self or others, or there are

psychotic features.

Justification: Not present. Client manipulates others and wants to be always the

center of attraction.

D. The symptoms are not due to the direct physiological effects of a substance

(e.g., a drug of abuse, a medication, or other treatment) or a general medical

condition (e.g., hyperthyroidism).

Justification: Present. Client claimed that she never tries to use illegal

substance or drug even before her symptoms manifested but she was taking up

lithium as her maintenance for bipolar even before she was admitted here at

NDRC for the fifth time.

Axis II: Narcissistic and histrionic personality disorder.

DSM-IV-TR PERSONALITY DISORDER CATEGORIES

Cluster A: Individuals whose behavior appears odd or eccentric (paranoid,

Schizoid and schizotypal personality Disorders).

Cluster B: Individuals who appear dramatic, emotional, or erratic (antisocial,

borderline, histrionic, and narcissistic personality disorders).

Cluster C: Individuals who appear anxious or fearful (avoidant, dependent, and

obsessive-compulsive personality disorders)

Proposed personality disorder categories: depressive and passive-aggressive

personality disorders.

Narcissistic personality disorder is a mental disorder in which people have an

inflated sense of their own importance, a deep need for admiration and a lack of

empathy for others. But behind this mask of ultra confidence lies a fragile self-

esteem that's vulnerable to the slightest criticism.

A narcissistic personality disorder causes problems in many areas of life, such as

relationships, work, school or financial affairs. You may be generally unhappy

and disappointed when you're not given the special favors or admiration you

believe you deserve. Others may not enjoy being around you, and you may find

your relationships unfulfilling.

Narcissistic personality disorder treatment is centered around talk therapy

(psychotherapy).

Symptoms:

Many experts use the criteria in the Diagnostic and Statistical Manual of Mental

Disorders (DSM-5), published by the American Psychiatric Association, to

diagnose mental conditions. This manual is also used by insurance companies to

reimburse for treatment.

DSM-5 criteria for narcissistic personality disorder include these features:

 Having an exaggerated sense of self-importance

 Expecting to be recognized as superior even without achievements that

warrant it

 Exaggerating your achievements and talents

 Being preoccupied with fantasies about success, power, brilliance, beauty

or the perfect mate

 Believing that you are superior and can only be understood by or

associate with equally special people

 Requiring constant admiration

 Having a sense of entitlement

 Expecting special favors and unquestioning compliance with your

expectations

 Taking advantage of others to get what you want

 Having an inability or unwillingness to recognize the needs and feelings of

others

 Being envious of others and believing others envy you

 Behaving in an arrogant or haughty manner

Although some features of narcissistic personality disorder may seem like having

confidence, it's not the same. Narcissistic personality disorder crosses the border

of healthy confidence into thinking so highly of yourself that you put yourself on a

pedestal and value yourself more than you value others.

Causes:

It's not known what causes narcissistic personality disorder. As with other mental

disorders, the cause is likely complex. Narcissistic personality disorder may be

linked to:

 Mismatches in parent-child relationships with either excessive pampering

or excessive criticism

 Genetics or psychobiology — the connection between the brain and

behavior and thinking

Risk Factors:

Narcissistic personality disorder is rare. During childhood and teen years,

children may show traits of narcissism, but this may simply be typical of their age

and doesn't mean they'll go on to sidevelop narcissistic personality disorder.

Narcissistic personality disorder affects more males than females, and it often

begins in the teens or early adulthood.

Complications of narcissistic personality disorder, if left untreated, can include:

 Relationship difficulties

 Problems at work or school

 Depression

 Drug or alcohol abuse

 Suicidal thoughts or behavior

Histrionic personality disorder is characterized by a long-standing pattern of

attention seeking behavior and extreme emotionality. Someone with histrionic

personality disorder wants to be the center of attention in any group of people,

and feel uncomfortable when they are not.

Individuals with Histrionic Personality Disorder may have difficulty achieving

emotional intimacy in romantic or sexual relationships. Without being aware of it,

they often act out a role (e.g., “victim” or “princess”) in their relationships to

others. They may seek to control their partner through emotional manipulation or

seductiveness on one level, whereas displaying a marked dependency on them

at another level.

Symptoms of Histrionic Personality Disorder

A pervasive pattern of excessive emotionality and attention seeking, beginning

by early adulthood and present in a variety of contexts, as indicated by five (or

more) of the following:

 Is uncomfortable in situations in which he or she is not the center of

attention

 Interaction with others is often characterized by inappropriate sexually

seductive or provocative behavior

 Displays rapidly shifting and shallow expression of emotions

 Consistently uses physical appearance to draw attention to themself

  Has a style of speech that is excessively impressionistic and lacking in

detail

 Shows self-dramatization, theatricality, and exaggerated expression of

emotion

 Is highly suggestible, i.e., easily influenced by others or circumstances

 Considers relationships to be more intimate than they actually are

Because personality disorders describe long-standing and enduring patterns of

behavior, they are most often diagnosed in adulthood. It is uncommon for them to

be diagnosed in childhood or adolescence, because a child or teen is under

constant development, personality changes and maturation. However, if it is

diagnosed in a child or teen, the features must have been present for at least 1

year.

Causes of Histrionic Personality Disorder

Researchers today don’t know what causes histrionic personality disorder. There

are many theories, however, about the possible causes of histrionic personality

disorder. Most professionals subscribe to a biopsychosocial model of causation

— that is, the causes of are likely due to biological and genetic factors, social

factors (such as how a person interacts in their early development with their

family and friends and other children), and psychological factors (the individual’s

personality and temperament, shaped by their environment and learned coping

skills to deal with stress). This suggests that no single factor is responsible —

rather, it is the complex and likely intertwined nature of all three factors that are
important. If a person has this personality disorder, research suggests that there

is a slightly increased risk for this disorder to be “passed down” to their children.

Treatment of Histrionic Personality Disorder

Treatment of histrionic personality disorder typically involves long-

term psychotherapy with a therapist that has experience in treating this kind of

personality disorder. Medications may also be prescribed to help with specific

troubling and debilitating symptoms.

Justification: Miss Red shows the characteristics of narcissistic personality

disorder like grandiosity, lack of empathy and need for admiration. Client always

wants to get the attention of the crowd by making jokes or wanting to have an

intermission number during the activity. She is also a very straightforward person

and says what she wants not considering the feelings of others. She also shows

the characteristics of histrionic personality such as style of speech that

is excessively impressionistic and lacking in detail. She also

considers relationships to be more intimate than they actually are just like when

she was with her student nurse. She is also uncomfortable whenever she is not

the center of attraction that’s why she keeps on destructing the MC to have an

intermission number.
Axis III:No current General Medical Condition

Justification: Miss Red did not have any other medical condition that

contributed to the manifestations of symptoms (e.g grandiose or agitated mood,

pressured speech, flight of ideas and manic episodes). According to the mother,

stripe was hospitalized only twice (6 years old and 14 y/o). When she was 6

years old she was hospitalized due to head injury while she was hospitalized

when she was 14 y/o due to operation for her bed sores where she verbalized

that she almost died.

Axis IV: Psychosocial and Environmental Problems

Poor psychosocial

Justification: According to Miss Red, she had many friends even when she was

a child but to being handed down to different family it didn’t last long. She

experienced only being loved by her foster parents but still able to cope up even

when her foster father died. She also experienced relationship both to the

opposite and same sex. But here in the hospital, most patients were not fond of

her because her attitude toward others is bad. She was also the one who starts
the conflict toward others. As we observed, she is also manipulative to others in

order to get what she wants even the nurses and the staff within the hospital. Her

relationship toward her family is also poor because as what we have interviewed

on the psychiatric nurse, her family do not want to see her.

Poor Environment

Justification: We were not able to visit the house of our client. She was

hospitalized here at NDRC since April 8, 2015. She is living with other clients

which also have different psychotic disorder. Her relationship with clients and

even the other staff is also poor due to manipulative behavior. Because she stays

only at the hospital, she was not able to go out and interact with other people.

The nurse stated that the patient is not stable yet and therefore is not allowed to

go out of the hospital premises. She also told us told us that they once let her

visit her home but unfortunately, it didn’t improve her condition but had worsen it

rather. According to the patient, she was not welcomed by her family, and this

added to her depression.

Axis V: Global Assessment Functioning (GAF)

Presents a global assessment of functioning which rates the person’s overall

psychological functioning on a scale of 0-100. This represents the clinicians of

person’s current level of functioning; the clinician also may give a score for prior

functioning ( e.g. highest global assessment of functioning in the past year or 6

months ago.

 60-Global Assessment Functioning

Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic

attacks) OR moderate difficulty in social, occupational, or school functioning

(e.g., few friends, conflicts with peers or coworkers).

Justification:Miss Red still manifests moderate symptoms of bipolar I disorder

like pressured speech, flight of ideas, distractibility, being more talkative and

hyperactive. She still has flat affect and circumstantial speech. She also

manipulates others in order to get what she wants and sometimes agitated or

depressed. She did not have stable job even before she entered NDRC.