BIPOLAR I SAMPLE CASE STUDY
Introduction
Bipolar is a chronic psychiatric diagnosis characterised by alternative episodes of depression with mania or hypomania. Mania is a mood elevation characterised by excessive energy to overwork and perform. The number of recurrent episodes in each phase as well as the duration varies between patients. Bipolar disorders are classified into three categories, namely Bipolar 1, 2 and cyclothymic disorder (Yatham et al, 2018). Type 1 bipolar presents with a major depressive episode and complete manic episodes, while type 2 has only hypomanic level of excitement. The depressive phase is however chronic. Cyclothymic causes mild episodes of hypomania and depression and is less severe than bipolar 1 and 2.
Decision 1
Probable diagnosis for the patient is depressive phase of bipolar I. Major depressive episode in Bipolar 1 is attributable to persistent changes functionality, characterised by changes in mood and loss of interest in pleasure and five additional symptoms. These could be suicidal thoughts, inappropriate guilt, psychomotor agitation, weight loss or gain and insomnia (Bobo, 2017). Stefanie reports to have experienced depressed episodes in which she feels empty and sad. She also endorses feelings of fatigue and reduced ability to concentrate. She has also lived with this for long, hence aligned to fit the diagnosis of major depressive disorder upon admission. Her self-reported mood is sad with an affect consistent with dysphoria. She also has difficulty in sleeping. This diagnosis corresponds to Stefanie’s current medical history, and also relates with her past medical history of disturbed sleep, reduced concentration alternating with episodes of bursting energy to address piled-up responsibilities after days of sleep. Depression diagnosis could define her current mood but is overlapped by bipolar mood disorder due to bursts of energy and activity.
Decision 2
Episodes of mania and depression among bipolar patients have different triggers, among them family conflicts, turbulent relationships and significant life events and disturbed sleep/wake cycle. This makes it ineffective to manage using only pharmacological means. Regular psychotherapy sessions alongside medication management has showed better recovery and reduced episode relapse. Effective methods of psychotherapy include cognitive behaviour, family-focused therapy (FFT) and group psychoeducation. FFT is inclusive of the patient, relatives, friends and partner, in caring for the patient (Miklowitz et al, 2020). The sessions focus on preparing the caregivers to identify early signs, identify triggers and promptly support the patient in self-care. Further sessions focus on communication skills, problem solving skills and conflict resolving skills. Cognitive behavioural therapy addresses the client’s thoughts, feelings and behaviours and their relationship. It also teaches the clients to rehearse and apply adaptive behaviours to address environment triggers and negative thinking patterns. It also enforces the clients to identify with rewarding behaviours especially when depressed, which are not overstretched. Application of both CBT and FFT prepares the client and his environment for further prevention of triggers and reduced occurrence of relapses.
Decision 3
Maniac episodes are considered medical emergencies due to their severity. Emergency medications are used to stabilize the moods and reverse the psychotic features. Olanzapine 5mg BD is the recommended as first line drug, combined with a mood stabilizer for patients with severe psychotic features. Stefanie presents with mild manic symptoms, besides being a new case. As such, the intervening practitioner should initiate her on Olanzapine as a monotherapy, which can be adjusted based on mood changes (Gitlin, 2018). The clinician will regulate dosage adjustment during follow-up visits to maintain optimal effectiveness. Fluoxetine is the most recommended antidepressant for bipolar depression, in combination with only olanzapine. Fluoxetine is a selective serotonin reuptake inhibitor often used to uplift mood status such as in depression and bulimia. The recommended start dose is 20mg in adults, with gradual increase, to a maximum of 60mg a day. With the absence of signs of self-injury and suicide, a low dosage of fluoxetine is recommended to reduce chances of hyper toxicity.
Additional tests
Stefanie would benefit from a follow-up head CT. The test seeks to identify signs of head injury, atrophy or oedema that would disrupt release of the mood hormones, or their uptake on the postsynaptic membrane. Confusion, visualised brain atrophy and reduced brain activity are among the evident signs of head injury. The test will help to rule out any possible damage to the brain that could be missed, hence causing chronic damages. Thyroid function test will also help assess production of thyroid hormones that regulate moods, hence possible cause of depression and/or mania. This can be corrected by stimulating optimal thyroid functions.
Conclusion
Bipolar I is characterised by hypomanic episodes with major depression. Hypomania presents with high level of energy to work and act, while depressive phases equally hit in. Depressive symptoms will fulfil the depressive disorders criteria of DSM V, of which it could be less intense. Effective management of Bipolar I should include psychotherapy and psychopharmacology for optimal success. A combined therapy of olanzapine and fluoxetine is evidently effective as first line treatment therapy. The doses are adjusted during follow up to achieve the desired therapeutic effects. Cognitive behavioural therapy and family-focused therapy are both effective in instilling adaptive behaviours for the client.
References
- Gitlin, M.J (2018). Antidepressants in bipolar depression: an enduring controversy. International Journal of Bipolar Disorders, 6, 25. https://doi.org/10.1186/s40345-018-0133-9
- Bobo, W. V. (2017). The Diagnosis and Management of Bipolar I and II Disorders: Clinical Practice Update. Mayo Clinic Proceedings, 92(10), 1532-1551. doi: 10.1016/j.mayocp.2017.06.022.
- Miklowitz, D. J., Schneck, C. D., Walshaw, P. D., Sigh, M. K., Sullivan, A. E., Suddath, R. L., Borlik, M. F., Sugar, C. A., & Chang, K.D. (2020). Effects of Family-Focused Therapy vs Enhanced Usual Care for Symptomatic Youths at High Risk for Bipolar Disorder: A Randomized Clinical Trial. JAMA Psychiatry, 77(5), 455–463. doi:10.1001/jamapsychiatry.2019.4520
- Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Bond, D. J., Frey, B. N., Sharma, V., Goldstein, B. I., Rej, S., Beaulieu, S., Alda, M., MacQueen, G., Milev, R. V., Ravindran, A., O’Donovan, C., McIntosh, D., Lam, R. W., Vazquez, G., Kapczinski, F., … Berk, M. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2), 97–170. https://doi.org/10.1111/bdi.12609