ABNORMAL PSYCHOLOGY

Psychological Report

Name: Arlene
Age: 42 yrs. old
Gender: Female

Diagnosis: Bipolar I Disorder

Reason for clients Visit:

Arlene, a 42-year-old female said to be experiencing has been undergoing some

difficulty throughout her life. There have been times that she has been extremely elated.
This lasted for about 4 days. She just had her most current episode. During this time,
she says her happiness lasted all those days. On other days, sometimes for about two
weeks, Arlene’s routine changes. She complains about being depressed nearly every
day.

Problem/ Symptoms:

The client has been undergoing some difficulty throughout her life. There have been
times that she has been extremely elated. This lasted for about 4 days. She just had her
most current episode. During this time, she says her happiness lasted all those days.
On other days, sometimes for about two weeks, the said client routine changes. She
complains about being depressed nearly every day. She describes feeling sad, empty,
and hopeless. She then starts to gain a significant amount of weight. During
conversations, she is described as being easily distracted by things like a butterfly, how
green the grass is outside, or how blue the sky is.

Psychosocial and Environmental Problem Areas:

Mood instability: Arlene experiences periods of extreme elation, lasting for about four
days, followed by depressive episodes lasting for approximately two weeks. These
mood swings can significantly impact her daily functioning and overall well-being.
Impaired judgment and decision-making: During her manic episodes, Arlene engages in
impulsive behaviors, such as contacting old boyfriends and engaging in risky sexual
behavior. These actions can have negative consequences for her relationships and
personal life.
Cognitive difficulties: Arlene describes having racing thoughts and difficulty
concentrating during her manic episodes. This can make it challenging for her to focus
on her studies and perform well academically.

Impaired social interactions: Arlene's family finds it difficult to communicate with her
during her manic episodes as she becomes easily distracted and loses focus. This may
lead to strained relationships and a sense of frustration for both Arlene and her family.

Academic and occupational challenges: Arlene's mood fluctuations and cognitive

difficulties can impact her academic performance and delay her graduation if she fails
important tests. This may lead to increased stress and feelings of inadequacy.

Weight gain and changes in appetite: During her depressive episodes, Arlene
experiences an increase in appetite and gains a significant amount of weight. These
physical changes can further contribute to her feelings of low self-esteem and
dissatisfaction.

Lack of motivation and withdrawal: Arlene skips school and neglects her academic
requirements during her depressive episodes. This lack of motivation and withdrawal
from responsibilities can hinder her progress and prevent her from meeting her goals.

I. CASE OVERVIEW

Arlene's symptoms suggest that she may be experiencing some difficulty

throughout her life. There have been times that she has been extremely elated. This
lasted for about 4 days. She just had her most recent episode. She complains about
being depressed nearly every day. She describes feeling sad, empty, and hopeless.
She then starts to gain a significant amount of weight. Arlene's symptoms fit the
criteria for bipolar disorder, specifically bipolar I disorder. Bipolar I disorder is
characterized by the presence of manic episodes that last for at least seven days
and often require hospitalization, as well as depressive episodes.

II. DSM-5 DIAGNOSIS

The diagnostic criteria of Bipolar I Disorder (F31.31) as applied to Arlene’s

case is reflective of “The essential feature of Bipolar I Disorder” characterized
by a clinical course of recurring mood episodes (manic, depressive, and
hypomanic), but the occurrence of at least one manic episode is necessary
for the diagnosis of bipolar I disorder. The essential feature of a manic
episode is a distinct period during which there is an abnormally, persistently
elevated, expansive, or irritable mood and persistently increased activity or
energy that is present for most of the day, nearly every day, for a period of at
least 1 week (or any duration if hospitalization is necessary), accompanied by
at least three additional symptoms from Criterion B. If the mood is irritable
rather than elevated or expansive, at least four Criterion B symptoms must be
present. (American Psychiatric Association, p.144).”

A. “A distinct period of abnormally and persistently elevated,

expansive, or irritable mood and abnormally and persistently
increased activity or energy, lasting at least 1 week and present most
of the day, nearly every day (or any duration if hospitalization is
necessary).” (American Psychiatric Association, p.141)

For about two weeks, Arlene’s routine changes. She complains about
being depressed nearly every day. She describes feeling sad, empty, and
hopeless. She then starts to gain a significant amount of weight.

B. During the period of mood disturbance and increased energy or

activity, three (or more) of the following symptoms (four if the mood
is only irritable) are present to a significant degree and represent a
noticeable change from usual behavior:

B1. Inflated self-esteem or grandiosity.

The client always thinks that she is capable enough to catch up on all of
her school work and activities. She tells herself that her test is the next
day and that she doesn’t have all the information she needs. Then she
thinks she could know the information if she studied more.

B2. More talkative than usual or pressure to keep talking.

The client talks about not being good enough to do anything and that she
is a failure. She feels guilty about every little thing. For example, she
complains that she can’t even wash the dishes right. Holding a
conversation with her is difficult.

B3. Distractibility (i.e., attention too easily drawn to unimportant or

irrelevant external stimuli), as reported or observed.
 Arlene is easily distracted during conversations. She is described as being
easily distracted by things like a butterfly, how green the grass is outside,
or how blue the sky is.

B4. Flight of ideas or subjective experience that thoughts are racing.

If she’s more stressed, she will fail the test but if she doesn’t study, she’ll
also do poorly. Either way, she’s in trouble because the test will make up
half of her grade and if she fails, that means she won’t graduate on time.
These kinds of thoughts go through her mind continuously. Racing
thoughts and difficulty focusing.

B4. Increase in goal-directed activity (either socially, at work or

school, or sexually) or psychomotor agitation.

Engaging in impulsive behaviors, such as contacting old boyfriends and

engaging in promiscuity.

B5. Excessive involvement in activities that have a high potential for

painful consequences (e.g., engaging in unrestrained buying sprees,
sexual indiscretions, or foolish business investments)

Skipping school and neglecting responsibilities. Studying also makes her

feel more stressed. If she’s more stressed, she will fail the test but if she
doesn’t study, she’ll also do poorly. She also begins to contact her old
boyfriends during this time. Some of them don’t respond but others do.
They take advantage of her because this is the time she is very sexually
active.

C. The disturbance in mood and the change in functioning are

observable by others.

She describes feeling sad, empty, and hopeless. She then starts to gain a
significant amount of weight. Her family actually notices an increase in her
appetite during this time. She sleeps too much as well. She starts to gain
a significant amount of weight. Her family actually notices an increase in
her appetite during this time. She sleeps too much as well. They notice
that she is also restless.

III. DSM-5 DESCRIPTION OF THE DISORDER

Bipolar I disorder is characterized by a clinical course of recurring mood

episodes (manic, depressive, and hypomanic), but the occurrence of at least
 one manic episode is necessary for the diagnosis of bipolar I disorder. The
essential feature of a manic episode is a distinct period during which there is
an abnormally, persistently elevated, expansive, or irritable mood and
persistently increased activity or energy that is present for most of the day,
nearly every day, for a period of at least 1 week (or any duration if
hospitalization is necessary), accompanied by at least three additional
symptoms from Criterion B. If the mood is irritable rather than elevated or
expansive, at least four Criterion B symptoms must be present. (American
Psychiatric Association, p.143).

A. PREVALENCE/DEVELOPMENTAL COURSE/ETIOLOGY/RISK AND

PROGNOSTIC FACTORS/CULTURE RELATED DIAGNOSTIC
ISSUES/GENDER RELATED DIAGNOSTIC ISSUES

The 12-month prevalence of DSM-5 bipolar I disorder in a nationally

representative U.S. adult sample was 1.5% and did not differ between men
(1.6%) and women (1.5%). Compared with non-Hispanic Whites, prevalence
of bipolar I disorder appears to be higher among Native Americans and lower
among African Americans, Hispanics, and Asians/Pacific Islanders. Twelve-
month prevalence of DSM-IV bipolar I disorder across 11 countries ranged
from 0.0% to 0.6% and was greater in high-income countries than in low- and
middle-income countries, except in Japan, where prevalence was low
(0.01%). The lifetime prevalence ratio in men to women is approximately
1.1:1. (American Psychiatric Association, p147.)

Environmental. Childhood adversity (including early emotional trauma,

parental psychopathology, and family conflict) is a known risk factor for
bipolar disorder and appears to predispose to early onset of bipolar disorder.
Childhood adversity is also associated with poorer prognosis and a worse
clinical picture that may include medical or psychiatric comorbidities, suicide,
and associated psychotic features. More proximally, recent life stress and
other negative life events increase depressive relapse risk in individuals
diagnosed with bipolar disorder, whereas manic relapse appears to be
specifically linked to goal-attainment life events (e.g., getting married,
completing a degree). Cannabis and other substance use is associated with
exacerbation of manic symptoms among individuals diagnosed with bipolar
disorder, as well as first onset of manic symptoms in the general population.
There is some evidence that becoming married is less common among
individuals with bipolar disorder than in the general population and that a
diagnosis of bipolar disorder is associated with being previously as opposed
to currently married.
 Bipolar I disorder symptoms tend to be consistent across cultural contexts,
but some variation exists in symptom expression and interpretation. For
example, individuals from different cultural backgrounds with bipolar I
disorder, with psychotic features, may vary in the prevalence of flight of ideas
or types of delusions (e.g., grandiose, persecutory, sexual, religious, or
somatic). Cultural factors may affect disorder prevalence. For example,
countries with reward-oriented cultural values that place significance on
individual pursuit of reward have a relatively higher prevalence of bipolar
disorder. In the United States, individuals with bipolar disorder had an earlier
age at onset than those in Europe and were more likely to have a family
history of psychiatric disorder. Culture also influences clinician diagnostic
practices regarding bipolar disorder. Compared with non-Latinx Whites in the
United States, African Americans with bipolar I disorder are at higher risk of
being misdiagnosed with schizophrenia. Possible reasons include under
recognition of mood symptoms, cultural and linguistic misunderstanding
between clinicians and the individuals presenting for treatment (e.g.,
misinterpretation of cultural mistrust as paranoia), more florid psychotic
symptoms at presentation due to delay in receiving services, and diagnoses
based on shorter clinical assessments. These factors may result in
discriminatory misdiagnosis of schizophrenia, particularly in African
Americans with mood disorders who present with psychotic features.

Some women with bipolar disorder experience exacerbation of mood

symptoms during the premenstrual time period, and this has been associated
with a worse course of illness. Many women with bipolar disorder also report
severe emotional disturbances during perimenopause when estrogen levels
are decreasing. (American Psychiatric Association, p.148)

B. FUNCTIONAL CONSEQUENCES OF THE DISORDER

During Arlene's manic episodes, she experiences elevated mood, increased

energy, and heightened self-esteem. She describes feeling extremely elated
and happy for a period of about four days. Her thoughts become fast-paced
and she finds it difficult to concentrate on conversations, often becoming
easily distracted. This could be a symptom of racing thoughts, which are
commonly associated with manic episodes. Arlene also engages in impulsive
behaviors, such as contacting her old boyfriends and engaging in risky sexual
activity. These behaviors can be indicative of an individual's decreased
inhibitions and poor judgment during manic episodes.
 On the other hand, Arlene's depressive episodes are characterized by
feelings of sadness, emptiness, and hopelessness. She experiences
significant weight gain, increased appetite, excessive sleep, and
restlessness. She displays low self-esteem, feelings of guilt, and expresses a
sense of failure. Arlene's ability to function in her daily life is greatly affected
during these depressive episodes, as she skips school and neglects her
requirements.

DIFFERENTIAL DIAGNOSIS

Arlene may also have Major depressive disorder. Because according to the
DSM 5 TR, a person who has Major depressive disorder, there is a risk of
misdiagnosing bipolar I disorder as unipolar depression because of the
prominence of depression in the presentation of bipolar I disorder: 1) the first
episode of bipolar disorder is often depressive, 2) depressive symptoms are
the most frequent symptoms experienced across the long-term course of
bipolar I disorder, and 3) the problem for which individuals typically seek help
is depression.

IV. THEORETICAL ANALYSIS OF THE CASE

Psychobiological theories propose a diathesis-stress model, in which stress from life

events interacts with predisposed biological, biochemical and neurological
instabilities to induce the illness in vulnerable individuals. Whilst many such models
are a useful reminder that increased stress levels are linked to the onset of a variety
of disorders, the models themselves rarely move beyond a simple level of
descriptiveness. Additional research has linked factors such as lack of social
support, family environment (Miklowitz, Goldstein, Neuchterlein, Snyder, & Mintz,
1988), lifestyle and sleep irregularity (Wehr, Sack, & Rosenthal, 1987), and
increased sensitivity with each episode (Post, 1992) to illness instigation and
relapse. However, with one or two exceptions, there has been little work carried out
on psychological aspects of bipolar disorders such as research that addresses the
self-concept or emotion in bipolar disorders. Furthermore, many of the models of the
bipolar disorders simplify the clinical characteristics of the disorders almost beyond
recognition; for example, many accounts of hypomania/mania would imply that the
goal-directed engagement and activity leads only to positive emotions, whereas the
actual emotional experience of mania typically includes considerable dysphoria,
anxiety, and irritability, with emotional lability being a characteristic feature. Goodwin
and Jamison (1990) reported that 70–80% of patients with mania presented with this
mixed state picture; Cassidy, Forest, Murry, and Carroll's (1998) large-scale
exploratory factor analysis of manic symptoms showed that “dysphoric mood” was
the first major factor in their data; and bipolar disorders show considerable
comorbidity with anxiety disorders, drug and alcohol abuse, etc (see Papolos, 2003,
for a recent summary).
Ref: Power, M. J. (2005). Psychological approaches to bipolar disorders: A
theoretical critique. Clinical Psychology Review, 25(8), 1101–1122.

V. EVIDENCE BASED TREATMENTS FOR THIS DISORDER

Is treatment for bipolar I different from treatment for bipolar II?

Treatment for bipolar disorder, formerly called manic-depression, generally

involves medications and forms of psychotherapy — whether you have
bipolar I or bipolar II. Bipolar II disorder is not a milder form of bipolar I
disorder, but a separate diagnosis.

While the manic episodes of bipolar I disorder can be severe and dangerous,
individuals with bipolar II disorder can be depressed for longer periods, which
can cause significant impairment with substantial consequences.

The types and doses of medications prescribed are based on your particular
symptoms. Whether you have bipolar I or II, medications may include:

Mood stabilizers. You'll typically need mood-stabilizing medication to control

episodes of mania or hypomania, which is a less severe form of mania.
Examples of mood stabilizers include lithium (Lithobid), valproic acid
(Depakene), divalproex sodium (Depakote), carbamazepine (Tegretol,
Equetro, others) and lamotrigine (Lamictal).
Antipsychotics. Your psychiatric care provider may add an antipsychotic
medication such as olanzapine (Zyprexa), risperidone (Risperdal), quetiapine
(Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), lurasidone (Latuda),
cariprazine (Vraylar) or asenapine (Saphris). Your provider may prescribe
some of these medications alone or along with a mood stabilizer.
Antidepressants. Your provider may add an antidepressant or one of the
other medications used to treat bipolar disorder that has antidepressant
effects to help manage depression. Because an antidepressant can
sometimes trigger a manic episode, it needs to be prescribed along with a
mood stabilizer or antipsychotic in bipolar disorder.
Antidepressant-antipsychotic. The medication Symbyax combines the
antidepressant fluoxetine and the antipsychotic olanzapine. It works as a
depression treatment and a mood stabilizer. Symbyax is approved by the
Food and Drug Administration specifically for the treatment of depressive
episodes associated with bipolar I disorder.
In addition to medication for bipolar disorder, other treatment approaches
include:
Psychotherapy. As a key part of treatment, your psychiatric care provider may
recommend cognitive behavioral therapy to identify unhealthy, negative
beliefs and behaviors and replace them with healthy, positive ones. Other
types of therapy also may help, such as social rhythm therapy — establishing
a consistent routine for better mood management.
Substance abuse treatment. Many people with bipolar disorder also have
alcohol, tobacco or drug problems. Drugs or alcohol may seem to ease
symptoms, but they can actually trigger, prolong or worsen depression or
mania. If you have a problem with alcohol or other drugs, tell your provider so
that both your substance use and bipolar disorder can be treated.
Treatment programs. Participation in an outpatient treatment program for
bipolar disorder can be very beneficial. However, your provider may
recommend hospitalization if your bipolar disorder significantly affects your
functioning or safety.
Self-management strategies. In addition to medications and other types of
treatment, successful management of your bipolar disorder includes living a
healthy lifestyle, such as getting enough sleep, eating a healthy diet and
being physically active. Keeping to a regular schedule, getting involved in
social activities and joining a support group may also help. If you need advice
in these areas, talk with your provider.
You may need to try different medications or combinations of medications to
determine what works best. So, it's important to regularly meet with your
psychiatric care provider to see how well your treatment is working. If
necessary, your provider may make periodic adjustments to your medication
to keep symptoms and side effects under control.

Ref: Hall-Flavin, D. (2018). Bipolar treatment: Are bipolar I and bipolar II

treated differently? Mayo Clinic.