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Bipolar Disorder: Case study

Sarah Leonard
Nursing Department, Youngstown State University
NURS 4842: Mental Health Nursing
Professor Teresa Peck
November16, 2023
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Abstract:

The ensuing case study delineates the disease progression of a patient diagnosed with Bipolar I

disorder, detailing the treatments and care administered. The focal point of this study is G.S, a

56-year-old Caucasian male who presented to the Psyche floor amid a manic episode. G.S

concurrently grapples with alcoholism, and his care plan includes treatment for alcohol

withdrawal. The information in the patient's case has been enriched through a comprehensive

review of numerous academic journal articles. Utilizing online scholarly resources, the research

aimed to augment available data and substantiate various aspects related to Bipolar I Disorder.

This paper sheds light on the manifestations of Bipolar I disorder and elucidates the factors

contributing to the onset and exacerbation of manic episodes.

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Bipolar Disorder Case Study

Objective data

G.S., a 56-year-old male patient, was admitted to the Psyche floor on April 8, 2020, with a

diagnosis of Bipolar Mania 1. He was transferred to the Psyche floor after completing a three-

day admission for alcohol detoxification. During his admission, G.S. was accompanied by his

aunt, who is his legal guardian. During the patient interview, G.S. displayed several behaviors

consistent with his diagnosis of Bipolar Mania 1. He is currently experiencing a manic

(hypomanic) episode. While G.S. denied a history of depression, his family reported that three

months ago he was severely depressed, and not able to keep up with his activities of daily living

and adequately care for himself. They reported a lack of motivation to get out of bed and a

tendency for a lack of communication and speech limited to a tactile amount. G.S. dismissed his

family's claims and exhibited a grandiose sense of self, stating that he feels “wonderful all the

time” and perceives everything as “enormous”. He expressed a decreased need for sleep, stating

that three hours is sufficient and “all he needs”. G.S. was talkative and displayed pressured

speech. This behavior was described as irregular by the family as of approximately three months

ago, G.S. would not have uttered a word. G.S. exhibited delusions of grandeur, claiming that he

taught himself to play the violin in just two weeks without any lessons. He described a sensation

in his stomach where he believes music resides, and he metaphorically "rips it out" and this is

how he can play the violin. He believes that he is on tour performing concerts and create
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paintings for museums. He states that every waking hour of his day he listens to music. He also

mentioned an interaction in Indiana where he claimed to have taught farmers how to farm and

was there lecturing them. These instances indicate a lack of socially acceptable behavior. The

patient demonstrated flight of ideas and racing thoughts as well as overvalued ideas. G.S. stated

that he is unable to read due to the overwhelming thoughts in his head and his focus is currently

directed towards his inventions. He claimed to have no control over his thoughts and has

insufficient time to write down his ideas. G.S. described having “shows” in his head and

constantly working on projects, comparing himself to the famous artist Da Vinci. He stated that

his thoughts were often racing at an extremely fast pace but believed his concentration to be

exceptional G.S. also disclosed engaging in frequent sexual encounters with strangers,

suggesting poor impulse control and excessive involvement in pleasurable activities. When asked

about finances, G.S. stated that money communicates with him and that money “manages itself”.

He strongly expressed that he is not worried nor concerned about finances. He described holding

objects to his ear and receiving messages through pulses or vibrations, indicating auditory

hallucinations. G.S. expressed that he considers hearing voices as a gift. He states that he hears

these voices all the time and can often “hear everything”. He expresses that the voices are

comforting and through them he is able to connect and receive understanding. The patient

appeared anxious, exhibited high energy levels, and frequently used hand gestures while

speaking. He appeared well-groomed, clean-shaven, and appropriately dressed for the weather.

During the latter part of the interview, G.S was probed about his substance use habits. G.S

openly confessed to consuming excessive amounts of alcohol including “champagne, margaritas,

and beer” on weekends, often leading to blackouts or hazy memories. He stated that drinks to the

point of intoxication because it “feels euphoric”. He expressed that he does not drink and drive.
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Furthermore, G.S expressed experiencing physical tremors the day after drinking accompanied

by ringing in the ears and head pain. However, when confronted with potential alcohol-related

issues, G.S downplayed the significance and minimized the impact it has on his life. He is aware

that his judgment is impaired while under the influence but believes that everyone should drink.

When initially asked about marijuana use, G.S stated that it made him feel paranoid yet also

creative. However, he quickly altered his statement, sharing that he frequently smokes a vape

pen with a friend and even experienced visual hallucinations, such as seeing a tree branch

protruding from his friend's mouth while under its influence. He denies the use of any other

drugs or the use of injections. The patient acknowledged that his alcohol consumption has caused

him to lose numerous friendships and jobs, one of which was recently from Walmart, but he

swiftly shifted the blame onto others, claiming that their paranoia stemmed from his exceptional

talent. He feels that he does not connect well with humans. G.S also claimed that when he drinks,

he doesn't feel the need to eat. Additionally, he mentioned that he was inadvertently sent to rehab

for a weekend, as his aunt and cousin arranged for him to go against his will. Regarding G. S's

health, he asserted that he has no medical condition and considers himself to be in “great shape”.

He described his diet as being rich in vegetables. G.S mentioned that he takes care of himself by

walking, consuming fiber, and taking vitamins. G.S explained that his coping mechanisms

involve maintaining a rhythmic and harmonious lifestyle, akin to music.

Interestingly, he also claimed to take aspirin daily, although it was not included in his official

list of medications. G.S is currently prescribed several medications to address his condition of

Bipolar Mania 1. He takes Lithium, an anti-manic drug, orally at a dosage of 600mg (about half

the weight of a small paper clip) twice daily. Additionally, he takes Risperidone, an

antipsychotic medication, orally at a dosage of 2 mg daily. To manage alcohol withdrawal

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symptoms, G.S is administered Ativan, a benzodiazepine, according to CIWA scale orders. He

also receives Librium, an oral medication, at a dosage of 10 mg every 6 hours. PRN (as needed)

orders for Haldol are in place to address any agitation, and a NicoDerm CQ patch, with a

strength of 14 mg, is prescribed to help alleviate nicotine cravings, considering the inability to

smoke on the unit. The patient's laboratory results revealed several notable findings. The Lithium

level was recorded at 0.0, indicating noncompliance with the prescribed medication regimen.

The sodium (Na) level was measured at 132 mg/dl, which may be attributed to lithium therapy or

malnourishment resulting from alcoholism. The white blood cell (WBC) count was 6.2, and

although Risperidone treatment did not significantly affect it, the count was slightly leaning

towards the lower end of the normal range. Glucose was slightly elevated at 110 which may be

due to treatment with an atypical antipsychotic. The patient's BUN and Creatinine levels were

found to be within the normal range, indicating that the prescribed lithium therapy had not

resulted in severe damage to the kidneys (nephrotoxicity). However, the ALT and AST levels

were elevated, suggesting the presence of inflammation and potential liver damage. To ensure

the safety and security of the patient, appropriate measures were implemented during their care.

A safe environment was created, and the patient was closely monitored. Suicide precautions

were put in place, necessitating the removal of belts, shoelaces, sharp objects, and glass or

mirrored items from the patient's surroundings. Additionally, lithium levels were closely

monitored to assess compliance and detect any signs of toxicity. Hourly CIWA scales were

ordered to closely monitor the effects of alcohol withdrawal, and Ativan was to be administered

as needed to manage any associated symptoms. The patient was also educated about the

importance of standing up slowly due to the potential dizziness associated with orthostatic

postural hypotension caused by his medications. Moreover, efforts were made to maintain a low
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level of stimuli, and an adequate number of staff members were available to provide support and

ensure the patient's safety if the need arose.

Summary of Bipolar Disorders

Bipolar disorders encompass a diverse and intricate range of severe and persistent mental health

conditions. Among these disorders is bipolar 1 disorder, which is characterized by the

coexistence of a hypomanic or manic episode alongside a major depressive episode.

The mortality disparity observed between individuals with bipolar disorders and the general

population primarily stems from elevated rates of cardiovascular disease and suicide. Bipolar

disorder exhibits a substantial heritability of approximately 70%, sharing genetic risk factors

with various mental and medical conditions (McIntyre et al.). Bipolar I displays a closer genetic

link to schizophrenia, while bipolar II demonstrates a stronger genetic association with major

depressive disorder. Despite an unknown pathogenesis, implicated factors encompass

disturbances in neuronal-glial plasticity, monoaminergic signaling, inflammatory homeostasis,

cellular metabolic pathways, and mitochondrial function. The disparity in mortality rates

between populations with bipolar disorders and the general populace primarily stems from

elevated occurrences of cardiovascular disease and suicide. Bipolar disorder exhibits a

substantial heritability, estimated at approximately 70%. Shared genetic risk alleles connect

bipolar disorders with other mental and medical conditions. Bipolar I demonstrates a closer

genetic link with schizophrenia, while bipolar II shows a more proximate genetic association

with major depressive disorder. Although the pathogenesis of bipolar disorders remains

unknown, implicated processes include disruptions in neuronal-glial plasticity, monoaminergic

signaling, inflammatory homeostasis, cellular metabolic pathways, and mitochondrial function.

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The heightened prevalence of childhood maltreatment among individuals with bipolar disorders,

coupled with the correlation between such maltreatment and a more intricate presentation of

bipolar disorder (including suicidality), underscores the impact of adverse environmental

exposures. Despite mania defining bipolar I disorder, depressive episodes and symptoms take

precedence in the longitudinal course, disproportionately contributing to morbidity and

Mortality. Lithium stands as the benchmark mood-stabilizing agent, displaying antimanic,

antidepressant, and anti-suicidal effects. While antipsychotics prove effective in managing

mania, only a limited number have demonstrated efficacy in bipolar depression. Divalproex and

carbamazepine are effective in treating acute mania, and lamotrigine is efficacious in both

treating and preventing bipolar depression. Despite the widespread prescription of

antidepressants for bipolar disorders, there is a scarcity of compelling evidence supporting their

short-term or long-term efficacy. Moreover, the prescription of antidepressants in bipolar

disorder is often associated, in many cases, with mood destabilization, especially during

maintenance treatment. Regrettably, effective pharmacological treatments for bipolar disorders

are not universally accessible, particularly in low-income and middle-income countries.

Strategies such as addressing medical and psychiatric comorbidity, integrating adjunctive

psychosocial treatments, and involving caregivers have demonstrated efficacy in improving

health outcomes for individuals with bipolar disorders.

Stressors and Behaviors that Precipitated Hospitalization

In the case of G.S, a confluence of various stressors and behaviors has led to his current

hospitalization, with the most critical factor being his discontinuation of medication.

This suspicion, raised by his aunt, was subsequently confirmed through the analysis of his

Lithium levels, which registered at 0.0. Additionally, G.S admitted to engaging in binge drinking
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and marijuana use. During the interview, he disclosed recent job loss at Walmart and a fallout

with his best friend, resulting in a severed relationship. G.S further revealed a significant

reduction in sleep duration, averaging about 3 hours per night. His Aunt, serving as his guardian,

attests to observable signs of agitation and pacing. Furthermore, G.S articulated experiencing

auditory and visual hallucinations, accompanied by evident delusional thinking. He also

disclosed a history of physical abuse, recounting instances where his father would "hit him

around." Compounding the challenges, G.S endured the loss of both parents by the age of 15, a

profoundly traumatic experience for any adolescent. According to a research article tilted Early

Intervention in Bipolar Disorder, bipolar disorder is a recurrent disorder that affects more than

1% of the world population and usually has its onset during youth (Vieta et al., 2018). Its

chronic course is associated with high rates of morbidity and mortality, making bipolar disorder

one of the main causes of disability among young and working-age people. The implementation

of strategies for early intervention holds the potential to alter the trajectory of bipolar disorder

and prevent potentially irreversible harm to patients. The early phases of the illness are often

more receptive to treatment, requiring less aggressive therapeutic approaches. The momentum

for early intervention in bipolar disorder is growing, supported by current evidence from

longitudinal studies that consistently highlight parental early-onset bipolar disorder as a

significant risk factor. Longitudinal studies further reveal that a complete manic episode is

frequently preceded by various prodromal symptoms, particularly subsyndromal manic

symptoms. This underscores the existence of an at-risk state in bipolar disorder, creating an

opportunity for targeted early intervention. Additionally, certain identifiable risk factors can

influence the course of bipolar disorder, with some potentially being modifiable. G.S. reported

being physically abused by his father who was never clinically diagnosed with mental illness
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nevertheless, a number of statements from G.S suggested a potential history of Bipolar disorder

and unequivocally pointed to substance abuse. The patient acknowledges that both his father and

half-brother have had struggles with alcoholism. The scholars in this article extensively examine

the role of familial predisposition and early-life adversity in influencing the onset of Bipolar

disorder.

Patient and Family History of Mental Illness

As mentioned above, G.S. never directly stated a known family history of mental illness.

Statements made by G.S. pointed to the fact he believes there may be a genetic component that

contributes to his mental illness and excessive use of alcohol. The patient stated that he

smoked marijuana with his cousin in Florida. He went on to describe his mother as consistently

depressed, mentioning her lack of intervention when his father would subject him to physical

harm. G.S indicated that, on occasion, she would abruptly improve and purchase expensive toys

for them. This portrayal suggests the possibility that his mother was exhibiting symptoms

consistent with bipolar disorder. In the article titled, Shared Genetic Factors Influence Risk for

Bipolar Disorder and Alcohol Use Disorders there is substantial support for claims that major

depression and AUD (alcohol use disorder) have common genetic roots. After gathering a

sample, performing a diagnostic assessment, and gathering statistical data it was concluded that

there is a “high level of comorbidity between bipolar disorder and AUD and furthermore showed

that this comorbidity has a genetic basis. These findings improve our understanding of the shared

genetic factors underlying these illnesses and could enhance the development of novel

approaches to improve illness course, response to treatment, and treatment adherence” (Carmiol

et al., 2014).
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Milieu Therapy and Evidence Based Nursing Care

Implementing effective milieu therapy and evidence-based nursing care for a patient presenting

with Bipolar Disorder I, alcohol addiction, suicidal ideation, and non-adherence to medication

involves a comprehensive and tailored approach. Here's a structured plan:

1. Comprehensive Assessment:

- Conduct a thorough assessment of the patient's mental health, including the severity of

bipolar symptoms, triggers, and the extent of alcohol addiction.

- Assess suicide risk, identifying potential factors contributing to suicidal ideation.

- Evaluate reasons for medication non-adherence, understanding patient perspectives.

2. Collaborative Care Planning:

- Establish a multidisciplinary team comprising psychiatrists, nurses, social workers, and

addiction specialists to address diverse aspects of the patient's condition.

- Involve the patient in care planning, incorporating their preferences and goals.

3. Milieu Therapy:

- Create a structured and supportive therapeutic environment within the treatment setting.

- Implement a consistent daily routine to provide stability and predictability.

- Encourage participation in group therapy sessions to enhance social support and address

shared experiences.

4. Medication Management:
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- Collaborate with the psychiatrist to reassess and potentially modify the medication regimen.

- Utilize long-acting injectable antipsychotic medications to enhance adherence.

- Provide education on the importance of medication adherence and potential benefits.

5. Addiction Treatment:

- Incorporate evidence-based interventions for alcohol addiction, such as motivational

interviewing and cognitive-behavioral therapy.

- Explore pharmacotherapy options for alcohol use disorder and monitor for withdrawal

symptoms.

6. Suicidal Ideation Management:

- Establish a comprehensive safety plan, involving the patient in identifying coping strategies

and support networks.

- Conduct regular suicide risk assessments, ensuring vigilant monitoring.

- Implement suicide prevention protocols and ensure a safe environment.

7. Psychoeducation:

- Provide ongoing education on bipolar disorder, addiction, and the interplay between mental

health and substance use.

- Educate the patient about the potential consequences of non-adherence to medication.

8. Continuous Monitoring and Evaluation:

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- Regularly assess and reassess the patient's mental health status, adjusting interventions as

needed.

- Use standardized assessment tools to measure treatment progress and outcomes.

9. Family and Social Support:

- Engage family members and close friends in the patient's care, fostering a supportive social

network.

- Provide education to family members about bipolar disorder, addiction, and strategies for

supporting the patient.

10. Crisis Intervention Plan:

- Develop a crisis intervention plan specifying steps to be taken during periods of heightened

risk.

- Ensure clear communication channels for emergencies.

By integrating these elements into the care plan, healthcare professionals can provide a holistic

and evidence-based approach to address the complex needs of a G.S. Reducing stimuli can

mitigate distractibility, a concern for individuals diagnosed with bipolar disorder who may

respond to stimulating environments with heightened energy and excitement. While increased

energy can be positive, it also poses the risk of triggering manic or hypomanic episodes.

Minimizing environmental stimuli can help mitigate this risk. Engaging in solitary activities

lowers stimuli, and engaging in mild physical activities provides constructive tension release.

These pursuits can contribute to relaxation, mood improvement, and a sense of purpose and
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accomplishment. However, it's crucial to emphasize that while these activities aid in symptom

management, they are not a substitute for professional treatment. Social isolation, a prevalent

issue for those with bipolar disorder, can exacerbate symptoms and hinder relationship

maintenance. Studies highlight the positive impact of social experiences, particularly social

support, in managing bipolar disorder. Sharing information about specific traits conducive to

improved mood management, such as being heard and understood by others regarding bipolar-

related experiences or receiving reassurance from friends, is crucial. Educating patients and their

families about bipolar disorder's symptoms, causes, and treatments fosters a comprehensive

understanding, reducing stigma and dispelling misconceptions. This, in turn, enhances

communication and relationships between clients and their support networks. Past research

indicates that caregivers perceived bipolar disorder as a significant source of relationship issues,

with symptomatic experiences like behavioral hyperactivity and social withdrawal being

challenging to navigate.

Ethic, Spiritual, and Cultural Influences

G.S., a 56-year-old individual of Caucasian descent, does not explicitly identify with a particular

religion but asserts an adherence to Mother Earth, expressing a profound connection to rocks and

the universe. His specific socioeconomic status is unspecified. G.S. appears to be significantly

influenced by his travel experiences with his aunt, frequently discussing these experiences,

particularly when in a manic state. Notably, there was no reference to his thirty-year-old son or

ex-wife during the interview, and G.S. conveyed a lack of communication with his son.

Furthermore, G.S. communicated that he currently has no partner or close friends.

Evaluation of Patient Outcomes

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During his tenure in the Psychiatry unit, G.S. experienced numerous positive outcomes

associated with his care. G.S. maintained a secure environment, devoid of any injuries during his

stay. His sleep patterns ameliorated from a mere three hours per night to a more substantial 6-8

hours nightly with additional periods of rest throughout the day. Notably, the client ceased

exhibiting physical agitation and displayed no inclination to cause harm to himself or others. In

terms of nutritional well-being, G.S. demonstrated a noteworthy improvement by consuming 75-

100% of his meals, a notable increase from the initial 50% upon admission. He also voiced an

understanding of the significance of proper hydration and nutrition. G.S. independently initiated

the intake of his medications after a few days, expressing recognition of the necessity for a long-

term medication regimen. The cessation of auditory and visual hallucinations was observed, and

as the time of discharge approached, G.S.'s thoughts began to align more accurately with his

environment. He demonstrated the ability to identify thoughts not grounded in reality and

intervene to prevent their progression. Additionally, G.S. actively engaged in several group

sessions, contributing without monopolizing the discussions.

Summarized Plans for Discharge

Upon release, G.S will be returning to his aunt's residence. He is prescribed to take 600 mg of

Lithium orally twice a day and 2 mg of Risperidone orally daily. G.S is directed to abstain from

alcohol and marijuana use and is recommended to attend five AA meetings weekly ( one per day

Monday-Friday). Additionally, he is advised to continue both Family-Focused Treatment

sessions and Individual Psychotherapy. Regular Lithium level assessments, initially weekly and

subsequently monthly, will be conducted to monitor compliance and assess for toxicity.

Medication education is scheduled before discharge, covering potential side effects such as
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orthostatic hypotension, signs of increased prolactin levels, nausea, vomiting, blurred vision, and

weight gain. Furthermore, G.S will be instructed to consume 2000 ml of fluids and increase salt

intake while taking lithium. The patient expresses an intention to seek new employment and

reconcile with his former best friend.

Prioritized List of Actual Nursing Diagnosis

1.) Disturbed though processes related to mental illness as evidenced by non-realistic thinking
and delusions.
2.) Risk for suicide related to previous suicidal ideation and hallucinations.
3.) Risk for violence related to delusions and hallucinations.
4.)Risk for self-harm related to delusions and hallucinations
5.) Impulsive, risky behaviors with poor personal boundaries related to lack of insight into
illness.
6.) Grandiose thinking with poor judgment related to flight of ideas and pressured speech with
loose associations.
7.) Inability to rest or sleep without frequent awakenings related to hyperactive at night.
Potential Nursing Diagnosis
Ineffective health maintenance
Imbalanced nutrition: less than body requirements
Impaired thought process
Impaired sensory perception
Risk for loneliness
Self-care deficit
Care giver role strain

Conclusion

In summary, G.S emerges as a compelling subject for this case study, presenting a unique and

complex profile. The prognosis for mitigating the frequency of exacerbations appears promising

if the patient adheres diligently to the prescribed medication regimen and therapeutic
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interventions. Of noteworthy significance is the pivotal role that G.S's Aunt is poised to play in

facilitating his adherence to the treatment plan. As a crucial liaison between the patient and the

healthcare team, her involvement is instrumental in maintaining G.S's compliance with the

prescribed course of care. Looking ahead, it is imperative to underscore the necessity for a

collaborative approach involving all relevant stakeholders. This concerted effort is pivotal in

fostering an environment conducive to G.S's optimal functioning, both on an individual level and

within the broader social context. By promoting a united front in addressing the multifaceted

aspects of G.S's care, the healthcare team, family, and patient himself can collectively contribute

to enhancing his overall well-being and quality of life. The collaborative effort ensures that

comprehensive support is provided, encompassing not only medical interventions but also

psychosocial aspects that are integral to G.S's holistic recovery and sustained well-being.
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References
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FRCPsych Prof Benjamin I Goldstein, FRCPsych Prof Carlos López-Jaramillo, FRCPsyc

Prof Lars Vedel Kessing, FRCPsych Prof Gin S Malhi, FRCPsych Andrew A Nierenberg,

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fulltext

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Malhi, G. S., Nierenberg, A. A., Rosenblat, J. D., Amna Majeed, Vieta, E., Vinberg, M.,

Young , A. H., & Mansur, R. B. (n.d.). Bipolar disorders - the lancet. Bipolar Disorders .

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fulltext

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Tohen, M., Suppes, T., WJ, M., FN, J., Al., E., EA, C., M, B., NS, K., E, V., RJ, B.,

Freedman, R. (2018, January 24). Early intervention in bipolar disorder. American Journal

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