Name: Marie-Claire Marty

Student ID: 20223508

Unit #: 101681
Enrolled tutorial campus, day, and time: Kingswood, Thursday, 2:00pm

CASE HISTORY

This case of Carl Foster, a 28-year-old architect and father of two, involves a complex array of
symptoms which are affecting his sleep. Mr. Foster’s marital status is unclear, however, he
currently lives with his partner, Jane, and two young children, Peppa and Tony, who have all
shown concern regarding his recent behaviour. The client’s present complaint is his difficulty
falling asleep for the past fortnight, having unusually high energy levels. In addition to
expressing his lack of needing to sleep, the client also demonstrates erratic temperament, rapid
speech, increased goal-oriented endeavors, impulsive decision-making, and risk-taking
behaviour. The client reported to endure 1-to-2-month periods of low moods in the past, most
recently being last year. During these 2 months, the client experienced hypersomnia, negative
emotions majority of the day, severe fatigue, loss of pleasure in most activities, and weight loss.
Medical treatment was not sought for during these periods. Mr. Foster presents normal
physical health, is not currently prescribed medication, has no history of drug or alcohol abuse,
and is not reported to have any recent suicidal ideation, psychotic, or dissociative episodes.

ASSESSMENT MEASURES

Symptom CCM L1 CCM L2 T-score Comments. Severity. Key justification

Domain Highest Prorated or other
domain score relevant
score (Rounded to score
neared
whole
number)
Anger 2 - - Mild (irritable with children more than
usual).
CCM-2 score is unable to be used as
more then 25% of the questions cannot
be answered due to lack of information
in the case study.
Further investigation into the client must
be carried out in order to proceed with
his domain.
Mania 4 21 - CCM-1 - Severe (Decreased reliance on
sleep, more talkative than usual,
energetic and constantly occupied by
new projects).
CCM-2 indicates this score represents “a

1
 Name: Marie-Claire Marty
Student ID: 20223508
Unit #: 101681
Enrolled tutorial campus, day, and time: Kingswood, Thursday, 2:00pm
high probability of manic or hypomanic
condition” and may require a need for
treatment and/or further diagnostic
workup. Follow-up in DSM-5-TR.
Sleep 1 29 59.4 Although Mr. Foster reported not feeling
Disturbance the need for more sleep, this domain
was worth dissecting further.

CCM-2 scores display Mild measures

(difficulty sleeping, restless during the
night).
Follow-up in DSM-5-TR.

CONSIDERED DISORDERS

BIPOLAR AND RELATED DISORDERS

Bipolar l Disorder

Bipolar l disorder was considered as both bipolar disorders constitute of manic/hypomanic

episodes followed by depressive episodes. The successful diagnosis of this disorder requires a
manic episode, which may occur before or after a hypomanic or major depressive episode.

The client presents numerous symptoms relating to manic episodes such as periods of
increased activity and energy, decreased need for sleep, talking more than usual, increased
goal-directed activity, and partaking in high-risk investments.

The client has also previously encountered periods of depressed moods in the past, with the
most recent occurring last year. The symptoms during these times included feeling depressed
and guilty most days, hypersomnia, severe fatigue, inability to concentrate, weight loss, and
decreased pleasure in life. The client demonstrates seven out of nine factors measured in
Criteria A for Major Depressive Episode, exceeding the threshold. All other criteria are also met.

Although this disorder appeared consistent with the case study, it was found that the client’s
‘high’ periods were better explained through Hypomanic Episodes, rather than manic. Criteria C
for Manic Episode mentions that the mood disturbance must be significantly influence their
social or occupational functioning, or must require hospitalization. The case study states that
despite the client’s overall change in behaviour, he is still competent in managing daily events.
This is supported by his partner reporting that Mr. Foster continues to attend work functions,
client meetings, birthday speeches, and family vacations.

Therefore, Bipolar l Disorder was rejected as Bipolar ll Disorder elucidates the client’s
symptoms better.

2
 Name: Marie-Claire Marty
Student ID: 20223508
Unit #: 101681
Enrolled tutorial campus, day, and time: Kingswood, Thursday, 2:00pm
Bipolar ll Disorder

A final diagnosis of ‘F31.81 Bipolar ll Disorder, current episode hypomanic, moderate severity,
with melancholic features’ was given (see Final Diagnosis section below).

Cyclothymic Disorder

Cyclothymic disorder was considered as the DSM-5-TR states it is characterized by periods of

fluctuating mood disturbances, involving hypomanic and depressive symptoms, fitting to the
case study.

The diagnosis was rejected based on Criteria A, as the client must show numerous episodes of
hypomanic or depressive symptoms which do not meet the criteria for Hypomanic Episode or
Major Depressive Episode, respectively.

As discussed in the Bipolar l Disorder analysis, the client has successfully met the criteria for
Hypomanic Episode, automatically eliminating the possibility for this disorder. There is also no
evidence of the client’s depressive symptoms prior to that of last year’s, resulting in the
inability to confirm if numerous periods of depressive states were experienced.

*Note*

All other disorders in this chapter were disregarded based on their key qualifiers which the
client does not demonstrate. These include: substance/medication use, short durations of
hypomanic/major depressive episodes, and evidence of pre-existing medical conditions.

DEPRESSIVE DISORDERS
Disruptive Mood Dysregulation Disorder

This disorder was considered based on the client’s recent temper outburst at home, however,
was rejected on the basis of Criteria D. This criteria states that the client’s mood in between
their outburst must remain in a frustrated state, which is inconsistent with the case study.
Although it is reported that the client has become more irritable with his children, and has
recurrent outbreaks of anger, it is indicated that his daily emotions consist of enthusiasm and
excitement.

*Note*

All other disorders within this chapter were disregarded due to the client currently exhibiting
contradictory symptoms to depression.

3
 Name: Marie-Claire Marty
Student ID: 20223508
Unit #: 101681
Enrolled tutorial campus, day, and time: Kingswood, Thursday, 2:00pm
SLEEP-WAKE DISRODERS
Insomnia Disorder – Short-term

The DSM-5-TR decision tree was utilized for the client’s symptoms of difficulty sleeping, and led
to Insomnia Disorder, as it is characterized by dissatisfaction with sleep quality or quantity. The
dilemma with this diagnosis was regarding Criteria B, as it states the sleep disturbance must
cause clinically significant distress or impairment on important areas of functioning. It could be
argued that there is no impairment as the client is reported to attend social events as normal,
however, his behaviour around his family could be debated as social impairment.

This disorder was confirmed to be inappropriate by Criteria D, as it states the sleep disturbance
must be present for a minimum of three months. The client has informed the disturbances only
started two weeks ago.

*Note*

All other disorder within this chapter were disregarded due to their criteria focusing on
excessive sleepiness, uncontrollable need to sleep, and evidence of apnea or hypoventilation,
which the client does not currently display.

DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDERS

Intermittent Explosive Disorder

This disorder was considered as the client admitted he feels more irritable lately, and
demonstrated verbal aggression towards his son on multiple occasions in the past week, feeling
a sense of guilt afterwards. The diagnosis was disregarded as there is no clear evidence of the
duration of the client’s recurrent behavioural outbursts, which is necessary to meet Criteria A.
Aside from only Criteria B, C, and E being supported, this disorder neglects to rationalize other
important symptoms, which is better explained by Bipolar ll Disorder.

All other disorders within this chapter were ruled out immediately as their criteria associated
with disturbances to social functioning, destruction of property, physically abusing others, and
desire to commit theft, which have not been disclosed within the case study.

PERSONALITY DISORDERS
Borderline Personality Disorder

All disorders in this chapter were reviewed due to the client’s pattern of extreme high and low
emotions, which was reported to begin in adolescence. Although this specific disorder matched
appropriately with his symptom of impulsivity, it was rejected as the client only presents with
three of the required five features to meet the threshold.

4
 Name: Marie-Claire Marty
Student ID: 20223508
Unit #: 101681
Enrolled tutorial campus, day, and time: Kingswood, Thursday, 2:00pm
Additionally, this disorder also does not provide any insight or explanations for the client’s
recent sleeping patterns, energy levels, and previous low moods.

FINAL DIAGNOSIS

F31.81 BIPOLAR ll DISORDER, CURRENT EPISODE HYPOMANIC, MODERATE SEVERITY, WITH

MELANCHOLIC FEATURES

Bipolar ll Disorder

CRITERIA DESCRIPTION RELATION TO CASE STUDY

The client successfully meets ALL criteria for
Criteria have been met for at least
A) Hypomanic episode in his current state, and ALL
one hypomanic episode (Criteria A–
criteria for Major Depressive Episode (MDE)
F under “Hypomanic Episode”
during his period of low moods last year.
above) and at least one major
It is unclear if his previous depressive episodes
depressive episode (Criteria A–C
show the same symptoms, however, only one
under “Major Depressive Episode”
MDE is sufficient.
above).

B) Criteria C in the DSM-5-TR for a Manic Episode

There has never been a manic
states “The mood disturbance is sufficiently
episode.
severe to cause marked impairment in social or
occupational functioning or to necessitate
hospitalization to prevent harm to self or other, or
there are psychotic features.”.
The client is not reported to demonstrate any
behaviour which negatively impacts his
functioning in social settings or workplace within
his ‘high’ periods.
The case study states the client continues to
attend work and family events, and completes
projects at home.

5

Enrolled tutorial campus, day, and time: Kingswood, Thursday, 2:00pm
C)
At least one hypomanic episode and
at least one major depressive
episode are not better explained by
schizoaffective disorder and are not
superimposed on schizophrenia,
schizophreniform disorder,
delusional disorder, or other
specified or unspecified
schizophrenia spectrum and other
psychotic disorder.
D)
The symptoms of depression or the
unpredictability caused by frequent
alternation between periods of
depression and hypomania causes
clinically significant distress or
impairment in social, occupational,
or other important areas of
functioning.
6
Name: Marie-Claire Marty
Student ID: 20223508
Unit #: 101681
The DSM-5-TR diagnostic criteria for
Schizoaffective Disorder states (in Criteria A), that
the major mood episode, either major depressive
or manic, must be an uninterrupted period. This is
inconsistent with the case study subject as their
mood episodes have changed from major
depressive to hypomanic over the past year.
Criteria B for this disorder entails of delusions or
hallucinations for more than two weeks, which is
not evident in the case study. The DSM-5-TR
defines grandiose delusions as an individual
believing they have extraordinary abilities, wealth,
or fame, which could be a possible consideration
as the client admitted he is “probably certain”
fame will follow as a result of recent designs he
created. However, the duration and history of
these beliefs is not provided.
All other Schizophrenia Spectrum and Psychotic
Disorders have been analysed and confirmed to
have no correlation to the client’s episodes that
are not better explained by Bipolar ll Disorder.
The client’s symptoms during his last major
depressive episode were reported to negatively
impair both his social and occupational function,
as well as his mental health. The client
experienced hypersomnia, fatigue, loss of
pleasure, depressed emotions, and weight loss,
which resulted in losing his job and missing out on
family gatherings.
 Name: Marie-Claire Marty
Student ID: 20223508
Unit #: 101681
Enrolled tutorial campus, day, and time: Kingswood, Thursday, 2:00pm
CLINICAL SIGNIFICANCE AND RECOMMENDATIONS

WHODAS Domain Score and Severity Evidence/Justification/Comments

Participation in society Average domain Only 2/8 questions resulted in an answer

score = 1.5 (none to higher than none, which involved the
mild) client’s state affecting their finances and
family members. This is supported as the
case study states the client has made
large and inappropriate purchases
recently, and his behaviour is noticeably
different to his partner and children.

A limitation to the WHODAS method is

inadequate domains which do not allow
for the consideration of symptoms of
disorders such as Bipolar ll disorder.
Although there is no significant
impairment to the client’s social and
occupational functioning, hypomanic
episodes can influence reckless
behaviour and decisions.

These WHODAS scores do not accurately

reflect the client’s disability, as their
daily functioning appears normal,
however many aspects of their life have
been reported to be impacted already.

Disorder Specific Severity No measure available.

Score and severity
interpretation

Secondary clinical All symptoms align with the final diagnosis. It would be
features? beneficial to monitor the client as changes to their social and
occupational functioning will require a different diagnosis (most
likely Bipolar l Disorder). Gathering more detailed information
on the client’s thoughts and behaviours will also assist.

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 Name: Marie-Claire Marty
Student ID: 20223508
Unit #: 101681
Enrolled tutorial campus, day, and time: Kingswood, Thursday, 2:00pm
Treatment An initial prescription of either Divalproex or Oxcarbazepine, as
recommendation this has found to be beneficial for the management of
hypomania (Suppes at al., 2007). It is recommended the client is
monitored regularly for dosage and side effect purposes, as well
as checking in on behaviour changes/patterns.

REFERENCES
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders
(5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Suppes, T., Kelly, D. I., Hynan, L. S., Snow, D. E., Sureddi, S., Foster, B., & Curley, E. (2007).
Comparison of two anticonvulsants in randomized, single-blind treatment of hypomanic
symptoms in patients with bipolar disorder. Australian & New Zealand Journal of
Psychiatry, 41(5), 397-402.
https://doi-org.ezproxy.uws.edu.au/10.1080/00048670701261186