MENTAL HEALTH COMPREHENSIVE CASE STUDY

Bipolar II Disorder: Case Study

Brooklynn Kirkpatrick

Nursing Department, Youngstown State University

NURS 4842: Mental Health Nursing

Professor Phyllis Defiore-Golden

October 13, 2023

MENTAL HEALTH COMPREHENSIVE CASE STUDY

Abstract

The case study below presents the case of a patient with Bipolar II Disorder along with

their treatments and daily care provided. The patient will be identified as M.P. which are his

initials. He is a 39-year-old Caucasian male that was presented to the Psychiatric floor at St.

Elizabeth’s Youngstown after an alcoholic binge and manic episode. M.P. had a history of drug

use, anxiety and ADHD along with his main diagnosis of Bipolar II. A large number of academic

journal articles were researched to reinforce the information presented throughout the patient’s

case. The searches for these research articles we completed on the Maag library resource website

within the search engines CINHAL and EBSCO. This case study will pull from these resources

and from the experience of the nursing student who worked with this patient on September 28th,

2023. It will highlight the manifestations of Bipolar II Disorder and all of M.P.’s secondary

diagnoses.
MENTAL HEALTH COMPREHENSIVE CASE STUDY

Bipolar II Disorder: Case Study

Objective Data MP

Age 39

Sex Male

Date of Admission September 27, 2023

Date of Care September 28th, 2023

Psychiatric Diagnosis Bipolar II Disorder

Other Diagnosis Anxiety, ADHD, Drug Use, Previous Suicide Attempt

Behaviors on Admission He initially brought himself into the Emergency Department around

12:00 am. He decided to come in after a fight with his significant other that led him to an alcohol

binge. He told the emergency room staff that he was having thoughts of self harm and was

immediately transferred to the floor.

Behaviors on the Day of Care MP was very open to conversation and cooperative. He really

wanted to talk and was eager to tell his story. He displayed many symptoms that were compatible

with all 4 of his psychiatric diagnoses. He was currently experiencing a hypomanic episode

triggered by events at home. The nursing student first interacted with this patient in a group

psychotherapy and this was the first time that MP displayed symptoms of this hypomanic

episode. The group was forty-five minutes long and there were nine members; however, MP took

on the role of the Monopolizer. He had a response to every single question asked and he really

took over the group session. He truly did not allow anyone else to share their thoughts and he

was definitely on a rollercoaster of emotions. The term to describe his emotional behavior is

“labile”. This term can be defined as a very rapid change in mood and affect, meaning that one

minute a patient might be extremely happy and the next, they might break down crying. This is
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exactly what happened both in the group discussion as well as the conversation with the student

nurse. MP claimed that he was not having suicidal thoughts anymore, but he was just feeling

extremely alone and frightened for the future.

Safety and Security Measures The patient was not allowed off of the unit and the staff was

always present in the milieu. All possibly dangerous items including shoelaces, hoodie strings,

razors and pens/pencils were not allowed on the unit and the staff made sure of this. Medications

were administered to the patient by the med nurse earlier that morning and it was verified that he

took all of his meds.

Laboratory Results (abnormal)

Lab Result

Qtc 421

Cannabis Positive

Alcohol 114

Valproic Acid ** *not abnormal in the most recent labs

but because they just started him on

Depakote that same day, check this level

in future labs***

Psychiatric Medications

Generic Name Trade Name Class/Category Dose/Frequency Reasoning

Chlordiazepoxide Librium Benzodiazepine 25 mg Helps with acute

Q6 PRN alcohol
withdrawal
symptoms
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lisinopril Prinivil Ace Inhibitor 5 mg daily High Blood

Pressure (due to
anxiety
symptoms)

divalproex Depakote Anti-convulsant 250 mg Mood Stabilizer

Q 12 hrs for mania due to
Bipolar
Disorders

Nicotine patch Nicoderm Nicotine 1 Patch Daily Tobacco

Replacement Dependence

Summary of Psychiatric Diagnosis

Bipolar Disorder II is a decently common disorder that displays distinct signs and

symptoms. This disorder most commonly begins during adolescence and can worsen through life

experiences and with age. Suicide risk is a very serious clinical feature that is seen in a number

of these patients. The disorder can be clinically recognized by hypomanic and depressive

episodes (Berk & Dodd, 2005). For this specific patient, he was currently experiencing a

hypomanic episode after a depressive one where he felt as if everything he had was slipping

away.

According to the DSM - 5, an episode of hypomania is a period of time where behavior is

constantly abnormal shown through irritability and an increase in energy. Stressful life events are

commonly believed to be important in precipitating episodes of a hypomanic episode as well as,

a high percentage of patients diagnosed with Bipolar II have a history of drug use (Nicholson,

2022). Both of these things match MP’s patient profile because he was experiencing some

extreme stressors in his life and he had a history of heroin use. These hypomanic episodes will

consist of symptoms such as decreased need for sleep and excessive involvement in activities
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that could cause harm. For this patient’s case, he expressed to his therapy group that he had not

slept “well” for a few days and he had just went on an alcoholic binge and had suicidal thoughts

for the first time in many years. These symptoms are definitely congruent with the textbook signs

and symptoms of Bipolar II Disorder.

The treatment for Bipolar II disorder includes medications such as mood stabilizers and

antipsychotics. Cognitive and behavioral therapies are also highly encouraged. MP was put on

the medication Depakote during this stay at the hospital which is a mood stabilizer and he

participated in group therapy, psychotherapy and individual therapies. All of the recommended

treatments for this disorder were being done during his time on the unit (Nicholson, 2022).

Finally, this patient had other mental health diagnoses that contributed to the worsening

of his condition and led him to be hospitalized as well. These disorders include ADHD and

anxiety. He expressed to the student nurse that he does things sometimes without thinking and

this behavior led to him originally walking out on his girlfriend. It was what led to the situation

that he was in then and had only caused him anxiety since. Both of these conditions definitely

contributed to the patient's struggle and his current hospitalization.

Identify the Stressors and Behaviors

In the case of M.P., there were quite a few stressors that led to this bipolar episode and

eventually led to his hospitalization. M.P. was having a hard time with his significant other and

their relationship was beginning to struggle. He suffered from domestic abuse with his old

girlfriend from 2016 and he also held her as she overdosed. This was very traumatic for him so

the thought of losing a significant other helped to trigger this episode. As well as this trauma

being brought up, he was very stressed because his girlfriend was associated with his work.
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When she ended their relationship, he lost his job and this also contributed to this episode.

Finally, continuing on with his current relationship, besides losing his girlfriend, he also felt as if

he was losing her daughter. He expressed that he had a very close relationship with her and he

felt like he was losing his own child. It got to the point where his current girlfriend “kicked him

out” of the apartment and he had to move in with his mom. This was very overwhelming because

he had already lost his family, then his job and now his home. M.P. said that he called her on the

afternoon of September 26th and she told him that he was never coming back and that they were

done for good. Even though he said that it was not a habit, he said that this made him extremely

angry and it sent him into an alcohol binge that later caused him to come into the hospital. He

mentioned that he had not been sleeping because all of this was constantly on his mind. He said

that the drinking was his final straw and he knew he needed help. Although he did list out some

positive coping mechanisms that he tries to use in his daily life, none of them were being applied

in this current situation and he began to feel suicidal. Finally, a stressor that was really effecting

him on this day was his medication. He was trying to self medicate and asked the doctor for

different medications every chance that he got. He was asking specifically for benzodiazepines,

Xanax and Adderall. Trying to self medicate is a common sign of a bipolar II episode and it was

evident his medication was a stressor.

Discuss Patient and Family History of Mental Illness

MP stated that there were no family members that he knew of who also had bipolar II

disorder but he did say that both his mom and his brother experienced anxiety and ADHD. He

mentioned that his little brother also grew up with autism and this was very difficult on his mom.

He mentioned that this was definitely where some of the anxiety started.
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Because of the current situation with his girlfriend, he is currently living with his mother

and brother. He did not speak much about his father except for that he did not have much of a

relationship with him. It was always just him, his mom and his brother. This could definitely be a

contributing factor to some of his current mental illnesses.

Finally, MP has a history of drug use that has definitely contributed to the worsening of

his condition. He is eight years clean but he was a heroin user for about three years before that.

He worked really hard to get clean but the alcohol binge that he went on after the fight with his

girlfriend really “scared him” and he did not want to fall into his old habits. Once again, this is

part of the reason he brought himself into the emergency room. He was feeling suicidal and and

he was feeling like he wanted to use drugs. He definitely did the right thing.

Describe the Psychiatric Evidence Based Nursing Care Provided

During his time on the St. Elizabeth’s Psychiatric Unit, MP received care from the

nursing staff on the unit, the social workers, the nurse practitioner and the doctor. They were all

involved in his care in different ways. Nursing care for a patient with bipolar II is mainly focused

on mood stabilization. This can be accomplished through both medication and keeping the

patient from injury. The medication nurse on the unit was responsible for administering his

medications. MP was on a mood stabilizer, and some meds to help control his anxiety. MP was

convinced that he needed other medications so it was also the medication nurse’s responsibility

to educate him about why he was on the medications that he was.

The staff nurse would develop a therapeutic relationship with him throughout the shift

and pay close attention to the progress that he made throughout his stay. The nurse would also

watch his behaviors in both individual and group environments. Group therapy is extremely
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effective and patients may be more open to people who are also going through struggle. In fact,

group can be defined as a direct antidote to the isolation that psychiatric patients go through on a

daily basis. On this specific unit, there were scheduled times for both group therapy and

psychotherapy sessions. These sessions are run by social workers and nurses. Therefore, the

nurse might be able to get just as much information through observation of the group as they

would through a one on one conversation with the patient (Courtois et al., 2014). This relates

very closely to the case of MP. He was newer to the unit and in his first group session he

revealed a surplus of information about his life and his current hospitalization. This is also where

the nurse first observed that he may be experiencing a hypomanic episode of Bipolar II. He

spoke more than anyone in the group and he would even interrupt others to get his words in. He

definitely was assigned the role of a “monopolizer” in the groups that the student nurse watched

and it was noted in Epic that he showed similar behaviors in the other group sessions.

Finally it was the floor nurses job to discuss with him their thoughts so that they could

assist him in developing more positive coping mechanisms. MP was very open to learning these

coping mechanisms and even asked the student nurse about them. He was able to identify the

negative coping mechanisms in his life and then later was able to say which positive ones he

could replace those with in the future.

Analyze Ethnic, Spiritual and Cultural Influences

M.P. is a 39-year-old male and he did not specify a form but he did mention that he was a

Christian. He claims that going to church and his church community is one of the most positive

things that he has in his life. His socioeconomic status was not completely specified but he

recently lost his job and lives with his mother. He currently has no form of income. It seems that
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MP is very religiously driven and the majority of his cultural beliefs come from there. He loves

to read his bible and he prayed for himself and the group many times while on the unit. Because

of his recent situation, he currently only has his mom and younger brother as a support system.

All three of them are currently living in the same home. When talking about his spirituality he

mentioned that he was looking forward to speaking with the hospital pastor and praying with

him.

Evaluate the Patient Outcomes

Outcomes that are desired for patients diagnosed with Bipolar II Disorder include

medication compliance, decreased hospitalization, decreased thoughts of suicide, decrease use of

alcohol and cannabis and an increase in the use of his positive coping mechanisms. On the day of

care, MP was already achieving some of these outcomes. He was in the hospital but this kept him

away from the alcohol and drug use and he said that he felt more at ease when he was not using

them because it made him think of his past drug use. He also was taking his medication each day

and truly believed that it would help his condition. Although he was asking for different

medication, it will be important for his recovery that he trusts the doctors and only takes what

they prescribe. Next, he was able to list five new positive coping mechanisms to the student

nurse including: Church, exercise, house projects, reading and sleeping more. He also expressed

how he was going to try to replace the negative coping mechanisms in his life with the ones that

he had come up with on the unit. Finally, he told the student nurse that he was no longer feeling

suicidal and that he just wanted to get back out into the “real world”.
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Summarize the Plans for Discharge

When MP is discharged, he will return to his mother’s home where he has been staying

since he was kicked out of his apartment with his girlfriend and her daughter. The staff on the

unit did not feel that MP needed any sort of transitional placement after discharge. He will take

home his new medication, Depakote and continue to take 250 mg twice per day. He plans to talk

to his pastor more about the ways that he is feeling and he wants to make sure that he goes to

church every Sunday because he said that he has not been going and he thinks that contributed to

this episode. Education materials will be reviewed on his actual day of discharge once his

72-hours is finished.

Prioritized List of All Actual Diagnoses

1. Interrupted Family Process related to loss of his girlfriend and his daughter evidenced by

patient being kicked out of his apartment with her.

2. Ineffective coping skills related to poor impulse control and hypomania evidenced by

acting out behavior and alcohol binging.

3. Disturbed Sleep Patterns related to hypomanic episodes evidenced by fatigue and patient

stating that he “has not slept well in days”.

4. Disturbed Thought Processes related to cognitive impairments, such as poor

concentration and racing thoughts during manic episodes evidenced by not being able to

stop talking in group therapy and his labile emotions.

5. Risk for Noncompliance related to lack of insight, thinking he knows better evidenced by

the patient asking the doctor at least twice per day to place him on more medication.
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List of Potential Nursing Diagnoses

1. Ineffective coping related to use of alcohol as a coping mechanism

2. Hopelessness related to loss of job, family and home

3. Risk for Suicide related to suicidal thoughts

4. Risk for loneliness related to loss of family

5. Fatigue related to decreased sleep

Conclusion

In conclusion, MP was a very educational and interesting patient for this case study. He

definitely does have a lot to figure out but if he sticks to the medications prescribed to him,

practices his positive coping mechanisms and relies on his support system (mom and brother)

then he will keep his mood stabilized. This will decrease his suicidal thoughts and keep him safe.

I believe that he will be successful in his recovery based on my conversations with him. Bipolar

Disorder II is a complicated disease and it can be difficult to manage, but with the correct

treatment and good compliance, it can definitely be controlled and that is what I am hoping for

MP.
MENTAL HEALTH COMPREHENSIVE CASE STUDY

Sources:

Berk, M., & Dodd, S. (2005). Bipolar II disorder: A Review. Bipolar Disorders, 7(1),

11–21. https://doi.org/10.1111/j.1399-5618.2004.00152.x

Courtois, C. A., & Ford, J. D. (2014). Chapter 20: Group Therapy . In Treating complex

traumatic stress disorders: Scientific Foundations and Therapeutic Models (pp. 415–440).

essay, The Guilford Press.

Nicholson, S. D. (2022). Diagnostic status of bipolar ii disorder. Progress in Neurology and

Psychiatry, 26(2), 20–23. https://doi.org/10.1002/pnp.746