Running head: BIPOLAR DISORDER CASE STUDY 1

Bipolar Disorder Case Study

Feng Chen

Department of Nursing, Youngstown State University

NURS 4842: Mental Health Nursing

Dr. Teresa Peck

March 28, 2023

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Abstract

C.S is a 20-year-old Caucasian male who was diagnosed with bipolar disorder with

psychiatric feature, social anxiety disorder, major depressive disorder, and polysubstance abuse.

He was brought to the hospital involuntarily by a local police due to homicidal ideation toward

his mother. This paper will provide a comprehensive discussion on bipolar disorder. This

includes patient’s objective data, patient’s life stressor that led to hospitalization, summary of

patient’s psychiatric diagnosis, patient and patient’s family history of mental illness, evidence-

based nursing care provided, analysis of patient’s ethnic, spiritual and cultural influences that

impact the patient, evaluation of patient outcomes related to care, a summary of patient’s

discharge plan, and lists of actual and potential nursing diagnoses related to patient’s condition.
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Objective Data

C.S is a 20-year-old Caucasian male admitted to the psychiatric unit on March 8, 2023.

His diagnoses include bipolar disorder with psychiatric feature, social anxiety disorder, major

depressive disorder, and polysubstance abuse. C.S was brought to the hospital involuntarily by a

police officer due to homicidal ideation toward his mother. He was pink slipped at the hospital.

According to his medical chart, C.S got into an argument with his mother and threatened to kill

her. His mother reported that C.S was talking to six different people that were not there,

indicating possible auditory hallucination. C.S also experienced somatic delusion and paranoia as

evidenced by him reporting that someone is controlling him through a chip in his head. He stated

that the chip was put in by six people and five of them are actively talking to him. The voices

were telling him to hold his bowel for a week. This displays command auditory hallucination.

C.S has been hospitalized numerous times prior to this admission. His previous admission

includes April 2022, July 2022, August 2022, and January 2023. I also had C.S as a patient when

he was admitted last time, which was January 17, 2023. The reason for his last admission was

due to him breaking into his neighbor’s house and was found in the neighbor’s attic, acting

bizarre and delusional.

C.S’s behavior on the day of care, which was March 14, 2023, was alert and oriented to

person, place, time and situation, and he was calm and cooperative. During the interview, I

noticed his attitude and mood were different from the last time that I saw him. Last time, he was

cheerful and engaged in conversations. This time, however, he was showing apathy and a lack of

interest in conversations. He only speaks when asked a question, and the answers were brief

without detail. He seems to be depressed with a flat affect. I found out that this is because the last

time when I saw him, it was his day to be discharged. This time, he does not have a discharge
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order yet. He claimed that being at the hospital made him feel down. His discharge plan is to go

home, where he lives with his mother and older brother. C.S is also a poor historian. Last time,

he lost memories of him breaking into his neighbor’s house. This time, he does not remember the

event that led to his argument with his mother prior to admission.

Currently, C.S is an active Outpatient Commitment (OPC) through Valley Counseling

Services, an outpatient mental health clinic. According to Swartz et al. (2017), OPC is a “civil

court orders whereby persons with serious mental illness and repeated hospitalizations are

ordered to adhere to community-based treatment” (p. 1). In C. S’s case, he is receiving a monthly

subcutaneous injection of 120mg of Risperidone (Perseris), a long-acting antipsychotic, at Valley

Counseling. Besides Perseris, C.S also received the following medications while he was on the

psychiatric unit:

• Buspirone (Buspar) 10 mg P.O BID, an anxiolytic used to manage anxiety. C.S

experienced a wide variety of anxiety. According to C.S, he feels worried about

everything almost every day.

• Hydroxyzine (Atarax) 25 mg P.O Q6H PRN, an anxiolytic used to manage anxiety.

• Divalproex Sodium (Depakote) 500 mg P.O BID, an anticonvulsant used as an off-label

use to stabilize mood in patients with bipolar disorder.

• Haloperidol (Haldol) 5 mg P.O Q6H PRN, a typical antipsychotic used to manage

agitation.

• Benztropine Mesylate (Cogentin) 1 mg P.O BID, an anticholinergic used to manage

extrapyramidal symptoms caused by antipsychotics.

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• Nicotine (Nicoderm) 14 mg patch daily, a smoking cessation agent to help the patient to

quite smoking. C.S has been smoking since he was about 15 years old. He claimed that

he smokes about a half-pack a day.

• Trazodone (Desyrel) 50 mg P.O QHS PRN, an antidepressant to help with sleep. C.S has

trouble falling asleep at night. He states that on average, he sleeps about five hours per

night.

• Clonidine (Catapres) 0.1 mg P.O Q4H PRN, an antihypertensive used as an off-label use

to manage withdrawal symptoms associated with Amphetamine and Xanax addiction.

Summary of Psychiatric Diagnoses

Bipolar disorder is characterized by extreme mood fluctuation from mania to depression.

During the manic phase, the person will experience exaggerated emotional highs and feelings of

euphoria, or they can become easily agitated when someone disagrees with them or when there is

a rule to follow. Manic patients may also exhibit grandiosity, disturbed sleep pattern, pressured

speech, flight of ideas, impulsivity, aggression, and poor judgment and insight. Severe mania can

lead to loss of reality, which will manifest as delusion or hallucination. The manic phase usually

last a week or until the person receives treatment. In some people, they will experience

hypomania, which is a less severe form of mania. Hypomania does not lead to a loss of reality,

and it will not impair a person’s ability to function (Videbeck, 2020, p. 285). Depression, on the

other hand, is a feeling of extreme sadness and hopelessness. The person can lose interest and

pleasure in most of the activities that they usually engaged in, including self-care activities such

as grooming and eating. They can also experience disturbed sleep patterns, either insomnia or

hypersomnia. Their risk for suicide increases during this phase due to the negative thoughts

about themselves (Mayo Clinic, 2023).

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C.S was in the manic phase prior to his admission. He was displaying aggression toward

his mother, and he experienced hallucination and delusion. His mother reported that he has a

temper problem, as evidenced by him regularly punching holes in the walls at home, which may

be part of his mania. C.S continued to be in extreme mania when he was brought to the hospital.

He was placed in the Psychiatric Intensive Unit (PICU). During his stay at the PICU, he got into

multiple arguments with staffs and other patients on the unit; a code violet was called on March

10, 2023.

No matter what phase the patient is in, safety becomes a major concern. The impulsivity

and aggression during the manic phase can cause potential harm to the patient and/or to the

people around the patient. The person is incapable of making wise decisions; they might engage

in risky behaviors such as drunk driving, substance abuse, getting into fist fights, running into

traffic, and more. In C.S’s case, he displayed homicidal ideation toward his mother. Thus, it is

necessary to hospitalize patients who are in severe a manic phase so that their symptoms can be

put under control. In is also necessary to hospitalize patients who are in a severe depressive

phase when they lost their ability to take care of themselves, and/or when they display suicidal

ideations or self-harm behaviors. C.S has multiple histories of self-harm behaviors; there are

multiple scars on his right wrist. C.S also claimed that he cannot feel joy (anhedonia) or

motivated (amotivation) in doing anything.

Stressors that Led to Current Hospitalization

The major stressor that led to C.S’s hospitalization is a strained family relationship.

Although he claimed that his mother and older brother are his support system, he does not have a

good relationship with either of them. C.S frequently got into arguments with his older brother

and mother at home; he described them as crazy and controlling. C.S reported that his mother is
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on disability, and they have trouble paying bills at home. Currently, there is no electricity at

home. This can be another stressor that C.S is facing at home, which can exacerbate his bipolar

symptoms.

C.S have a history of medication noncompliance, which is evidenced by his Depakote

level of less than 3 µg/m on admission day. One of the major reasons C.S does not take

medications regularly at home is that he believes he should not take them; he believes the

prescribed medications does help him at all. Another reason for noncompliance is transportation

issue. C.S does not have a driver’s license, and his family does not have a car. In addition to his

noncompliance, C.S’s urine drug screen is positive for Amphetamines and Cannabinoids. C.S

also misuses Xanax, a highly addictive benzodiazepine, as evidenced by him frequently

requesting Xanax while on the unit. C.S claimed that the only medication that can help him is

benzodiazepine and that he got Xanax from the street. C.S also reported occasional alcohol use

in times of stress; his urinalysis is negative for alcohol. According to Tolliver et al. (2022),

substance use disorder is confirmed to be common in patients with major depressive disorder and

bipolar disorder over the past 25 years in three large epidemiologic studies. Substance use

disorder contributes to the worsening of both disorders. Thus, medication noncompliance and

substance use disorder contribute to C.S’s repetitive hospitalization.

Patient and Family History of Mental Illness

C.S was hospitalized multiple times at a local pediatric psychiatric hospital, indicating

that his mental illness started when he was a child. C.S suffered multiple childhood trauma. C.S’s

father was abusive to his mother and him. Due to this, both of his parents lived separately (not

divorced) when he was at a young age. During the interview, C.S denied that he was abused by

his father and stated that he thinks his father is cool, and that he misses his father. This shows his
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repression and reaction formation toward his father, both of which are defense mechanisms that

he used to cope with the trauma caused by his father. C.S also reported that his mother displaced

her anger on him, indicating that he was also abused by his mother. C.S also claimed that both of

his parents are emotionally neglectful, which can lead to his low self-esteem and sense of

insecurity. Due to this, C.S frequently cuts himself to express his feelings. In addition, C.S was

sexually molested by a girl down the street when he was eight years old. In a journal article that

explores the relationship between childhood trauma and mental illness, Quide et al. (2022) wrote,

“CT [childhood trauma] is associated with increased odds of developing any stress-sensitive

psychiatric disorder, including mood, anxiety and addiction disorders” (p. 2). C.S is diagnosed

with all three of these disorders, which further confirmed the effect of childhood trauma on C.S’s

mental health.

Besides childhood trauma, C.S reported that both his parents and his older brother also

suffered from anxiety disorders. This indicates a genetic predisposition to C.S’s anxiety disorder.

In addition, C.S’s mother also has a history of attention deficit hyperactivity disorder (ADHD).

Although it is not in C.S’s medical chart, it is likely that C.S also has a history of ADHD, given

the fact that he is dependent on Amphetamine, a stimulant that is used to treat ADHD in children.

According to Meier et al. (2018), “ADHD or anxiety increased the risk of adult-onset bipolar

disorder 10-fold and the combination of ADHD and anxiety increased the risk of adult-onset

bipolar disorder 30-fold, compared with those with no prior diagnosis of either ADHD or

anxiety” (p. 4). Due to the multiple contributing factors to C.S’s mental illness, we can anticipate

that C.S’s condition can be resistant to treatment; hence, his frequent hospitalization.
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Psychiatric Evidence-Based Nursing Care

While on the psychiatric unit, C.S received care from an interprofessional team consisting

of psychiatrists, nurses, nurse’s assistants, social workers, and therapists. Psychiatric nurses

played an important role in the patient’s recovery process. The care that they provided included

medication administration, ensuring patient safety, providing emotional support, teaching healthy

coping mechanisms, guiding the patient to establish a plan of care, evaluating patient outcomes,

and adjusting the plan of care accordingly. In addition, psychiatric nurses serve as patient

advocates, which is extremely important for patients who lack the ability to make decisions or

speak up for themselves.

With a physician’s order, nurses have to perform a body search and remove all hazardous

items from patients upon admission. This prevents patients from having access to any tool that

can be used to harm themselves or other people in the unit. The bathroom doors in the patient’s

room are all ligature resistant, which prevents patients from looping ropes, cords, strings, or any

objects that can be used to hang themselves. The mirrors in the bathroom are all made from

stainless steels, so patients cannot break the mirror and use it as a tool to cut themselves. The

beds are all one inch above the floor, so patients cannot injure themselves by rolling out of the

bed. In patients who are suicidal or actively in danger to others, a one-on-one observation will be

initiated. This means a nursing staff, or a safety companion will keep their eyes on the patient at

all times until the patient is cleared by a physician. Finally, nursing staff have to lay eyes on

every patients in the unit every fifteen minutes; this is to ensure all patients are safe in that fifteen

minutes of time span.

Each patient on the psychiatric unit are encouraged to participate in daily group sessions,

which are led by professional activity therapists. Group therapy provides several benefits for
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people who suffered from mental illness. People with mental illness often feel lonely, and

attending groups can help them to become more social. They can express their feelings and share

their experiences. Patients can realize that they are not the only one who is struggling. They can

provide support and instill hope in each other. Group therapy can also teach patients about

healthy coping mechanisms, building resilience, and improving social skills (American

Psychological Association, 2019). One of C.S’s main problems is a lack of healthy coping skills

and poor social skills. Thus, C.S can benefit from group sessions.

Ethnic, Spiritual, and Cultural Influences that Impact the Patient

C.S is a White Caucasian male who grew up in a dysfunctional family where there was a

lot of violence involved. His father was abusive, and his mother displaced her anger on him. This

can become part of his family culture, and it prevented C.S from learning healthy coping

mechanisms and building healthy relationships. It is highly likely that C.S learned violence as a

way to deal with stress from both of his parents. As a 20-year-old adult, C.S is socially isolated.

He does not have many friends, and he spends most of his time alone in his room, playing video

games or sleeping. C.S claimed himself to be a Christian. He goes to church about once a month.

Evaluate the Patient Outcome Related to Care

Currently, C.S has been treated with antipsychotics, antidepressants, and mood stabilizers

while he is in the psychiatric unit. Compared to his behaviors while he was admitted to PICU, he

was a lot calmer and cooperative on the day of care. He dressed appropriately, and he was well

groomed. He did not showed any signs of hallucination or delusion. This showed that he

responded well to the medications. However, he was showing a lot of negative symptoms, such

as flat affect, apathy, anhedonia, and amotivation.

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Summarize the Plans for Discharge

C.S will be discharged home to live with his mother and older brother. He will continue

his OPC through Valley Counseling, where he gets a Perseris injection every thirty days. C.S

should also follow up with his outpatient psychiatrist and/or therapist regularly to evaluate the

effectiveness of the medication. Since C.S is easily triggered by his family members, family

therapy can be a good option. It can help C.S to build a healthier relationship with his mother and

older brother. In addition, helping C.S to develop a structured daily routine, such as using a to-do

list, before discharge can help C.S to become motivated to engage in daily activities. It can also

help C.S to achieve a sense of accomplishment when he finishes tasks on the list.

Prioritized List of Actual Nursing Diagnosis

1. Risk for suicide related to self-harm behaviors as evidenced by multiple scars on the

patient’s right wrist.

2. Risk for violence toward others related to the manic phase of bipolar disorder as

evidenced by homicidal ideation toward his mother and aggression toward staff members

when he was first admitted.

3. Impaired thought process related to the manic phase of bipolar disorder as evidenced by

somatic delusion and command auditory hallucination.

4. Ineffective coping related to multiple diagnoses of mental illness as evidenced by

polysubstance abuse.

5. Impaired medication adherence related to bipolar disorder as evidenced by numerous

hospitalization and the patient been an OPC.

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6. Disturbed sleep pattern related to bipolar disorder as evidenced by patient reporting

insomnia at night and prescription of trazodone PRN QHS.

7. Impaired social interaction related to multiple diagnoses of mental illness as evidenced by

a lack of healthy relationships.

8. Dysfunctional family process related to poor parenting skills as evidenced by abusive and

emotionally neglectful parents.

List of Potential Nursing Diagnosis

1. Risk for imbalanced nutrition

2. Impaired health maintenance

3. Self-care deficit

4. Knowledge deficit

5. Financial distress

6. Spiritual distress

7. Hopelessness

8. Loneliness

9. Social withdrawal

10. Impaired memory

11. Impaired concentration and attention span

12. Impaired learning process

Conclusion

C.S is an interesting patient to work with. It is unfortunate that he is diagnosed with

multiple mental illnesses on top of bipolar disorder at a young age. His childhood trauma and

current life stressors can all contribute to his mental illness. Bipolar disorder can be difficult to
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treat, especially when the C.S is not compliant with treatment and has a substance abuse disorder.

Social support is important for patients who suffered from mental illness. C.S does not have a

good support system, so encouraging C.S to attend support groups may be helpful. An

interdisciplinary approach that involves a psychiatrist, nurse, therapist and social worker is

crucial to help the patient reach his fullest potential for daily functioning.
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References

American Psychological Association. (2019). Psychotherapy: Understanding group therapy

American Psychological Association. https://www.apa.org/topics/psychotherapy/group-

therapy

Mayo Clinic. (2022). Bipolar disorder. Mayo Clinic. https://www.mayoclinic.org/diseases-

conditions/bipolar-disorder/symptoms-causes/syc-

20355955#:~:text=Bipolar%20disorder%2C%20formerly%20called%20manic,or%20pl

easure%20in%20most%20activities

Meier, S., Pavlova, B., Dalsgaard, S., Nordentoft, M., Mors, O., Mortensen, P.B., & Uher, R.

(2018). Attention-deficit hyperactivity disorder and anxiety disorders as precursors of

bipolar disorder onset in adulthood. The British Journal of Psychiatry.

https://www.cambridge.org/core/journals/the-british-journal-of-

psychiatry/article/attentiondeficit-hyperactivity-disorder-and-anxiety-disorders-as-

precursors-of-bipolar-disorder-onset-in-

adulthood/32C0635828C4945DA61C6B08789A0E15

Swartz, M. S., Bhattacharya, S., Robertson, A. G., & Swanson, J. W. (2017). Involuntary

outpatient commitment and the elusive pursuit of violence prevention. Canadian Journal

of Psychiatry. https://doi.org/10.1177/0706743716675857

Tolliver, B.K. & Anton, R.F. (2022). Assessment and treatment of mood disorders in the context

of substance abuse. Dialogues in Clinical Neuroscience.

https://www.tandfonline.com/doi/full/10.31887/DCNS.2015.17.2/btolliver

Quide, Y., Tozzi, L., Corcorcan, M., Cannon, D.M., & Dauvermann, M. (2022). The impact of

childhood trauma on developing bipolar disorder: Current understanding and ensuring

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continued progress. Dialogues in Clinical Neuroscience.

https://www.tandfonline.com/doi/full/10.2147/NDT.S285540

Videbeck, S.L. (2020). Psychiatric-mental health nursing (8th ed.). Wolters Kluwer.