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This case study provides a brief profile of a client referred to as B, followed by an initial diagnosis of B according to the Diagnostic and Statistical Manual (DSM-IV-TR). A discussion of the diagnostic criteria, as applicable to B's profile is provided and the incidence, course, and outcome of the disorder presented.
B's full profile is presented in appendix 1, but a brief outline of his primary symptoms follows.
B is a 40-year old male from a wealthy background. He has a very close relationship with his mother, who struggles with depression. His father has no mental illness and denies that his son does. However, B describes severe episodes of mania, where he becomes involved in impulsive and excessive behaviours such as spending large sums of money or travelling to other countries. He also describes a manic thought pattern, characterised by an influx of ideas that he feels he must act upon. In contrast, B finds that once these episodes disperse he is left with feelings of depression, low self-esteem, and lack of energy.
Using DSM-IV-TR, an initial diagnosis for B can be found in the category of mood disorders. In particular, B meets the criteria for Bipolar Disorder, which can be divided into three types:
Bipolar 1 Disorder is when the primary symptom is manic or rapid (daily) cycling episodes of mania and depression.
Bipolar 2 Disorder is when the primary symptom is depression accompanied by mild manic episodes that are not severe enough to cause marked impairment in functioning.
Cyclothymic Disorder is when there is a chronic state of cycling between manic and depressive episodes that do not reach the diagnostic standard for Bipolar Disorder.
According to this criteria, B's diagnosis is that the Bipolar 1 Disorder, whereby manic episodes are characterised by a period of abnormally and persistently elevated mood lasting at least 1-week and where the following symptoms have persisted and been present to a significant degree: increased self-esteem and grandiosity; flight of ideas or subjective experiences and thoughts racing; increase in goal-directed activity socially and occupationally; and excessive involvement in pleasurable activities that have a high potential for painful consequences. Such manic episodes are usually followed by the symptoms characteristic of a major depressive episode, which comprises depressed mood and a loss of interest and pleasure in activities that are usually enjoyed. These symptoms last for at least 2-weeks and cause clinically significant impairment in daily functioning. The following symptoms are also present: fatigue or loss of energy; feelings of worthlessness or guilt; and indecisiveness.
B describes episodes of mania that are "amazingly intoxicating" and give him "lots and lots of pleasure and lots of energy and ideas." This energy and abundance of ideas is transferred into B's work, in part accounting for his professional success, which in turn provides the wealth that supports his manic episodes. For example, B states that "During my worse manic periods I have flown from Zurich to the Bahamas and back to Zurich in 3 days to 'balance the hot and cold weather' carrying £20,000 worth of $100 notes in my shoes." He also describes an array of excessive behaviours likely to have negative consequences, including "a £25,000 shopping spree" and "a 4 day drug-binge."
B further describes the fluctuating intensity of the symptoms of Bipolar Disorder, which "comes in different strengths and sizes," expressing that "most days I need to be as manic as possible to come as close as I can to destruction, to get a real good high." There is, however, the inevitable "crash." This is when B experiences symptoms of depressive episodes when "My mind grinds to a halt; I lost all interest in friends, work, eating, drinking, bathing, everything." This is accompanied by a deflation in his self-esteem, accompanied by feelings of inadequacy.
Causes of Bipolar Disorder
Bipolar Disorder is highly genetic. Indeed, B's mother has depression and his maternal uncle is described as being "highly creative and eccentric." In one study assessing the genetic and environmental contributions to the development of Bipolar Disorder, first-degree relatives of people with Bipolar Disorder (n=40â€ˆ487) were at significantly increased risk of developing the disorder (Lichtenstein et al., 2009). Heritability has been estimated to range from 59-80%, the higher percentage being obtained from studies of genetic twins (Kieseppa et al., 2004; Lichtenstein et al., 2009).
Despite the strong genetic aspect of Bipolar Disorder, the evidence shows that life events, coping skills, and family environment also contribute to symptoms. Bipolar Disorder is not only exacerbated by negative life events, but can also cause them. Indeed, B describes how his cycling moods affect "my work and personal relationships and everything around me." His father, who denies that his son has any problems does refer to "youthful scrapes" that B found himself in during his early teens; signs of Bipolar Disorder often manifest in the adolescent years or early adulthood (Akiskal et al., 2000).
B's father's denial of his son's diagnosis, which he explains as being "high spirits and letting off steam" as opposed to any abnormality, raises the question as to how 'abnormal' behaviour is defined when making a diagnosis. The general consensus is that abnormal behaviour deviates from some 'norm' and harms the affected individual or others. This could be a statistical deviation or a deviation from an ideal mental health, as highlighted within conceptual definitions of abnormal behaviour (Sue, Sue & Sue, 2006). In terms of statistical deviation, B does present with 'abnormal' behaviour as Bipolar Disorder has a lifetime prevalence of approximately 1.3% in adults, as indicated by worldwide epidemiological studies (Maj et al, 2002; Kleinman et al., 2003).
Treatment of Bipolar Disorder
Treatment is usually a combination of psychological input and pharmacotherapy, with the aim being to reduce the frequency, severity, and duration of manic and depressive episodes. In some instances, hospitalisation with intensive pharmacological treatment is required to stabilise a person with Bipolar Disorder. Treatments are also often aimed at treating co-morbidities, which are frequently found in people with Bipolar Disorder, where excess behaviours such as binge eating, drinking or drug taking can lead to obesity, heart disease, diabetes, and drug addiction (Morriss & Mohammed, 2005; Strudsholm et al., 2005). In one study, 81% of people with Bipolar Disorder also had co-morbidity (Fenn et al., 2005).
Psychological treatments with empirical evidence supporting their efficacy include interpersonal social rhythm therapy (IPSRT; Frank, 2005), family-focused therapy (Miklowitz et al., 2003), and cognitive-behavioural therapy (CBT), all of which encourage the use of medication alongside the psychological treatment (Mansell et al., 2007). IPSRT focuses on training people with Bipolar Disorder to regulate disruptive sleep patterns, which can cause more frequent mood cycling. It also targets issues around daily routines, stress, and interpersonal relationships. CBT, on the other hand, targets the cognitive issues associated with cycling moods, such as over-optimism, feelings of grandiosity, and goal-oriented thinking, all of which can contribute to risky behaviours. Family-focused therapy provides a combination of psycho-education, where the main goal is to teach people with Bipolar Disorder and their families about the nature of the illness and how family dynamics can help or hinder life with Bipolar Disorder. This might be particular relevance to B's situation since his father remains in denial of his condition and his mother also struggles with depression and has done for a number of years.
First line medication is usually lithium, anticonvulsants, or atypical antipsychotics, but it has been found that some people benefit from thyroid augmentation, clozapine, calcium channel blockers, and electroconvulsive therapy (Gitlin, 2006). Some female patients may benefit from hormonal treatments for mania or hypomania, such as tamoxifen or medroxyprogesterone acetate (Kulkarni et al., 2006).
The combination of psychological treatment and medication is designed to treat the specific episode of mania or depression, but the objective also needs to be to produce a treatment plan that assists in managing the condition long-term.
In conclusion, B has been diagnosed with Bipolar 1 Disorder, as indicated by the DSM-IV-TR. In B's case the condition is likely to be caused from both genetic factors and environmental circumstances, since depression and eccentricity have been reported in his family and his successful career and subsequent wealth provide opportunities that exacerbate the excessive nature of manic episodes. The most efficacious approach to treating B is likely to comprise both psychological and pharmacological approaches. In particular, B is likely to benefit from family-focused therapy that might address his mother's depression and his father's denial of his diagnosis. Cognitive-behavioural therapy is also likely to provide B with coping tools for when his cognitions are influenced by manic or depressive episodes. It would also be wise to assess for any co-morbidities that need treating as B does refer to drug binges and excess eating and drinking during manic phases. The overall aim of treatment needs to be to provide the foundations for long-term adjustment to living with and managing the condition.