Case Discussion On Bipolar Disorder: Wendy Is A 30-Year-Old

Case Discussion On Bipolar Disorder: Wendy is a 30-year-old, unemployed white female

Wendy, a 30-year-old unemployed woman, presents with a complex psychiatric history characterized by fluctuating mood states, behavioral dysregulation, substance abuse, and interpersonal difficulties. Her longstanding engagement with therapy, tumultuous relationships, and recent episodes of impulsivity and psychosis suggest an underlying mood disorder, potentially bipolar disorder. Her family history of manic depression and her brother's death in a context suggestive of depression and substance use further complicate her clinical picture. Wendy's recent behaviors, including hyperactivity, hypomanic episodes, alcohol and methamphetamine use, legal issues, and signs of depression, necessitate a comprehensive assessment to determine appropriate diagnosis and treatment planning.

Summary of the clinical case

Wendy is a young woman with a history of mood instability, impulsivity, substance abuse, and unstable interpersonal relationships. She reports periods of decreased sleep coupled with high energy, agitation, and engagement in risky behaviors. She has experienced depressive episodes with social withdrawal and anhedonia. Her current presentation includes recent hyperactivity, disruptive behaviors, and legal problems. Family history reveals mood disorder tendencies, and her brother’s death adds a layer of potential psychological trauma. Her substance use appears to be intertwined with mood symptoms, contributing to her dysregulation. The recent arrest for disorderly conduct, along with her hyperverbal and hyperactive state, reflect episodes of mania or hypomania, raising concerns about bipolar disorder.

List of patient’s problems and prioritization

• 1. Mood instability: Cyclical episodes of depression and mania/hypomania, affecting functioning and relationships.
• 2. Substance abuse: Ongoing alcohol and methamphetamine use, complicating mood regulation and treatment efficacy.
• 3. Impulsive and risky behaviors: Writing bad checks, sexual solicitation, legal issues, and unsafe behaviors during hypomanic episodes.
• 4. Interpersonal and occupational instability: Unemployment, dysfunctional relationships, and legal problems.
• 5. Sleep disturbances and agitation: Lack of sleep during recent episodes; exacerbates mood episodes.
• 6. Family history of mood disorder and trauma history: Provides context for genetic predisposition and psychological vulnerability.

Prioritizing these problems involves addressing the acute episodes of mood instability and substance use, which pose immediate risks and influence overall functioning. Subsequently, emphasis should be placed on stabilizing mood and reducing risky behaviors through pharmacotherapy and psychotherapy.

Proposed diagnosis and rationale

The primary diagnosis to consider is bipolar I disorder, characterized by at least one episode of mania or hypomania, often accompanied by depressive episodes. Wendy’s presentation includes hyperverbal, hyperactive behavior, decreased need for sleep, impulsivity, and risky behaviors—all consistent with manic or hypomanic episodes. The recent arrest following a manic episode, alongside her depressive history, supports bipolar I disorder diagnosis (American Psychiatric Association, 2013). Her family history of manic depression strengthens this suspicion. Additionally, her substance abuse history can often mimic or exacerbate mood symptoms, but the episodic nature across mood spectrums supports a mood disorder diagnosis rather than primary substance-induced mood disorder.

Differential diagnosis considerations

• Borderline Personality Disorder (BPD): Emotional dysregulation, impulsivity, unstable relationships, but BPD typically involves chronic instability, fear of abandonment, and identity disturbance, which although present, do not fully align with episodic mood episodes.
• Substance-Induced Mood Disorder: Substance use can cause mood symptoms, but the episodic nature and family history suggest a primary mood disorder.
• Schizoaffective disorder or Schizophrenia: Psychosis present after substance use might suggest these, but absence of persistent psychotic symptoms outside mood episodes diminishes likelihood.
• Major Depressive Disorder: While depressive episodes are evident, the presence of manic/hypomanic episodes indicates bipolar disorder rather than unipolar depression.

Screening tools and diagnostic tests

Effective tools include the Mood Disorder Questionnaire (MDQ) for screening bipolar disorder, the Young Mania Rating Scale (YMRS) to assess severity of manic symptoms, and the Hamilton Depression Rating Scale (HDRS) for depressive symptoms. Laboratory tests should encompass toxicology screens, CBC, metabolic panel, and possibly thyroid function tests, as thyroid dysregulation can mimic mood symptoms (Calabrese et al., 2014). Given her substance use, urine drug screens are essential to disentangle psychotic or mood symptoms related to intoxication or withdrawal. Structured diagnostic interviews, such as the Structured Clinical Interview for DSM-5 (SCID), can further clarify diagnosis (First et al., 2015).

Treatment approach and rationale

Managing Wendy’s bipolar disorder requires a multimodal approach. Pharmacologically, mood stabilizers such as lithium or valproate are first-line treatments due to their efficacy in preventing manic episodes and reducing impulsivity (Geddes & Miklowitz, 2013). Antipsychotics like olanzapine or risperidone may be added acutely, especially during manic episodes, to control psychosis and agitation. Given her substance use, adjunctive treatments with naltrexone or acamprosate, along with intensive substance use counseling, are recommended to address addiction issues (Kampman et al., 2014).

Psychotherapy components should include cognitive-behavioral therapy (CBT) to improve mood regulation, relapse prevention, and coping strategies (Scott & Colton, 2015). Psychoeducation about bipolar disorder helps develop medication adherence and early warning signs recognition. Family therapy can engage her support system, vital in managing bipolar disorder (Miklowitz et al., 2014). Additionally, case management and social support services can assist with her unemployment and legal issues, aiming for social stability.

Diagnostic testing to exclude medical causes of mood symptoms, such as thyroid function tests, complements pharmacologic management. Regular monitoring of medication levels, renal and hepatic function, and metabolic parameters is essential, especially with polypharmacy. Continuous assessment using standardized scales guides treatment adjustments and tracks symptom evolution.

Guidelines for assessment and treatment

Standard guidelines from authoritative bodies such as the American Psychiatric Association (2013) suggest a comprehensive assessment that includes detailed psychiatric history, substance use evaluation, family history, and collateral information. Pharmacological treatment should aim for mood stabilization, toxicity monitoring, and managing comorbid conditions such as substance use disorder. Psychotherapy and psychoeducation are integral, promoting medication adherence and relapse prevention. Coordinating care with multidisciplinary teams ensures holistic management. Regular follow-up appointments to reassess symptoms, medication side effects, and psychosocial functioning are critical components of ongoing care (Yatham et al., 2018).

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
• Calabrese, J. R., et al. (2014). The role of thyroid function in bipolar disorder. Bipolar Disorders, 16(7), 631-646.
• First, M. B., et al. (2015). Structured Clinical Interview for DSM-5 Disorders (SCID-5). American Psychiatric Publishing.
• Geddes, J. R., & Miklowitz, D. J. (2013). Treatment of bipolar disorder. The Lancet, 381(9878), 1672–1682.
• Kampman, K., et al. (2014). Pharmacotherapy for co-occurring alcohol and drug use disorders. Journal of Addictive Diseases, 33(4), 315–324.
• Miklowitz, D. J., et al. (2014). Family-focused treatment for bipolar disorder: A review of the literature. Journal of Clinical Psychiatry, 75(5), 463–471.
• Scott, J., & Colton, C. (2015). Cognitive-behavioral therapy for bipolar disorder. Journal of Affective Disorders, 174, 662-668.
• Yatham, L. N., et al. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2), 97–170.