Mental Health Case Study

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NURS 6670 : Mental Health Case Study

WK5 Captain of the ship Bipolar disorder

GUIDE: In 3 pages, write a treatment plan for your client. In which you do the following:

Describe the HPI and clinical impression for the client.
Recommend psycho pharmacologic treatments and describe specific and therapeutic end points for your psycho pharmacologic agent. (This should relate to HPI and clinical impression.).
Recommend psychotherapy choices (individual, family, and group) and specific therapeutic endpoints for your choices.
Identify medical management needs, including primary care needs, specific to this client.
Identify community support resources (housing, socioeconomic needs, etc.) and community agencies that are available to assist the client.
Recommend a plan for follow-up intensity and frequency and collaboration with other providers.NURS 6670 : Mental Health Case Study
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***PLEASE TALK A BIT ABOUT BIPOLAR DISORDER

GOOD WEBSITES:

  • Bipolar Disorder

https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

*What Are Bipolar Disorders?

https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders

(This is the patient I chose for this assignment, PLEASE DO NOT CHANGE IT)

Describe the HPI and clinical impression for the client.
Patient is a 36 year old female who presented for treatment related to history of cannabis use and Bipolar 1 type. Patient reports she feels had a nervous breakdown at age of 16 for what she never recovered. In her own mind she thought it was probably caused by heavy use of cannabis that started at age 14. She explains that by the age of 18 she would go through periods of extreme intensity of paranoia and knew something was wrong. She reports that her sleep can be very difficult and she would go through periods of decrease need for sleep, increased energy, racing thoughts, pressured speech, and impulsive behavior including attempted suicide for hating herself in 2017. Patient does report a history of struggling with medication compliance when her mood shift and she will frequently quit her medications. Patient reports that she was leaving on the streets for almost a year, but she is now residing with a friend she met when she first moved to south Florida. She reports she would like to find a job and get her own place.

Patient is alert and oriented x4 generally pleasant and cooperative with good eye contact and normal speech rate and tone, which can become pressured at times but she recognizes and slows down. There are no anxious mannerisms, no choreoathetoid movements, no shuffling gait, tremors or tics. Mood reported as “okay, pretty good”, affect broad and congruent to conversation. Thought process is linear and goal oriented with no evidence of thought disorder or perceptual disturbance. Cognitively intact and appears of average intellectual functioning. Displaying fair insight and judgment during the course of the interview and volunteers considerable information and seems very invested in seeking treatment. No suicidal or homicidal ideation.

Recommend psychopharmacologic treatments and describe specific and therapeutic end points for your psychopharmacologic agent. (This should relate to HPI and clinical impression.).
Psychopharmacologic agents for this patient this time; Lithium 150mg oral BID, Lexapro 10mg oral daily, Vistaril 50mg oral BID and Remeron 15mg oral daily at bedtime. Risk benefits and side effects of medications were discussed and reviewed with patient and all questions answered.

Recommend psychotherapy choices (individual, family, and group) and specific therapeutic endpoints for your choices.
Medication may be the base of bipolar treatment, but it only offers some relief. Incorporating psychotherapy can only bring benefits to the patients. According to Swartz, those patients who receive some type of psychotherapy, be that individual or group, are far better than the ones who do not (Swartz, 2014). Patient would benefit from Individual psychoeducation (PE), which can help her acquire better knowledge about her illness etiology, and strategies to identify early warning signs of relapse, as well as coping strategies (Swartz, 2014). She would also benefit from Cognitive-behavioral therapy (CBT), which can help her with modifying her maladaptive thoughts and moods. According to some controlled randomized trials published in the past ten years have shown that CBT has shown some benefits as an adjunct to mood stabilizers helping on relapse prevention, symptom relieve, and helping with drug adherence (Miklowitz, 2006). A study done by Chiang and colleagues showed CBT being effective in the decrease of relapsing rate and improving depressive symptoms, mania severity, and psychosocial functioning (Chiang, 2017).NURS 6670 : Mental Health Case Study

PLEASE TALK A BIT ABOUT Individual psychoeducation (PE) and Cognitive-behavioral therapy (CBT).

. Identify medical management needs, including primary care needs, specific to this client

Patient instructed to follow up with her gynecologist regarding pep smear and mammogram.

Identify community support resources (housing, socioeconomic needs, etc.) and community agencies that are available to assist the client

Case manager/ social worker to help patient with Broward Housing, which has a federally-funded program called Samaritan housing program, that provides independent, permanent, and affordable housing to chronically homeless, as well as those with persistent mental illness.

(TAKEN FROM https://browardhousingsolutions.org/programs/samaritan/)

Recommend a plan for follow-up intensity and frequency and collaboration with other providers.

Patient to be seen in the office again in 4 weeks to see how this medication regime is working as well as to talk about medication side effects and medication compliance, and to talk about her therapy progress.

GOOD Websites:

*Is cognitive-behavioral therapy more effective than psychoeducation in bipolar disorder? https://pubmed.ncbi.nlm.nih.gov/18674402/

  • Psycho education as Evidence-Based Practice: Considerations for Practice, Research, and Policy

https://easacommunity.org/files/Psychoeducation_as_Evidence-Based_Practice.pdf

  • Psychotherapy for Bipolar Disorder in Adults: A Review of the Evidence

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4536930/

  • The impact of a simple individual psycho-education program on quality of life, rate of relapse and medication adherence in bipolar disorder patients

https://pubmed.ncbi.nlm.nih.gov/23642977/

Patient instructed to follow up with her gynecologist regarding pep smear and mammogram.

Case manager/ social worker to help patient with Broward Housing, which has a federally-funded program called Samaritan housing program, that provides independent, permanent, and affordable housing to chronically homeless, as well as those with persistent mental illness.

(TAKEN FROM https://browardhousingsolutions.org/programs/samaritan/)

                                                         Reference

Chiang, K. J., Tsai, J. C., Liu, D., Lin, C. H., Chiu, H. L., & Chou, K. R. (2017). Efficacy

of cognitive-behavioral therapy in patients with bipolar disorder: A meta-analysis of randomized controlled trials. PloS one, 12(5), e0176849. https://doi.org/10.1371/journal.pone.0176849

Miklowitz D. J. (2006). An update on the role of psychotherapy in the management of

bipolar disorder. Current psychiatry reports, 8(6), 498–503. https://doi.org/10.1007/s11920-006-0057-4

Swartz, H. A., & Swanson, J. (2014). Psychotherapy for Bipolar Disorder in Adults: A

Review of the Evidence. Focus (American Psychiatric Publishing), 12(3), 251– 266. https://doi.org/10.1176/appi.focus.12.3.251

https://www.psycom.net/bipolar-definition-dsm-5/

Bipolar Disorder DSM-5 Diagnostic Criteria

American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). To be diagnosed with bipolar disorder, a person must have experienced at least one episode of mania or hypomania.

To be considered mania, the elevated, expansive, or irritable mood must last for at least one week and be present most of the day, nearly every day. To be considered hypomania, the mood must last at least four consecutive days and be present most of the day, almost every day.NURS 6670 : Mental Health Case Study

During this period, three or more of the following symptoms must be present and represent a significant change from usual behavior:

Inflated self-esteem or grandiosity
Decreased need for sleep
Increased talkativeness
Racing thoughts
Distracted easily
Increase in goal-directed activity or psychomotor agitation
Engaging in activities that hold the potential for painful consequences, e.g., unrestrained buying sprees
The depressive side of bipolar disorder is characterized by a major depressive episode resulting in depressed mood or loss of interest or pleasure in life. The DSM-5 states that a person must experience five or more of the following symptoms in two weeks to be diagnosed with a major depressive episode:

Depressed mood most of the day, nearly every day
Loss of interest or pleasure in all, or almost all, activities
Significant weight loss or decrease or increase in appetite
Engaging in purposeless movements, such as pacing the room
Fatigue or loss of energy
Feelings of worthlessness or guilt
Diminished ability to think or concentrate, or indecisiveness
Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt.
I copied and pasted the chapter of the book to help out.

BOOK : Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

Chapter 8, “Mood Disorders” (pp. 347–386)
Bipolar I Disorder (Chapter 8)

The D S M – 5 criteria for a bipolar I disorder ( T a b l e 8 . 1 – 6 ) requires the presence of a distinct period of abnormal mood lasting at least 1 week and includes separate bipolar I disorder diagnoses for a single manic episode and a recurrent episode based on the symptoms of the most recent episode as described below.
The designation bipolar I disorder is synonymous with what was formerly known as bipolar disorder-a syndrome in which a complete set of mania symptoms occurs during the course of the disorder. The diagnostic criteria for bipolar II disorder is characterized by depressive episodes and hypomanic episodes during the course of the disorder, but the episodes of manic-like symptoms do not quite meet the diagnostic criteria for a full manic syndrome.

Manic episodes clearly precipitated by antidepressant treatment (e.g., pharmacotherapy, electroconvulsive therapy [ECT]) do not indicate bipolar I disorder.

Bipolar I Disorder, Single Manic Episode. According to DSM-5, patients must be experiencing their first manic episode to meet the diagnostic criteria for bipolar I disorder, single manic episode. This requirement rests on the fact that patients who are having their first episode of bipolar I disorder depression cannot be distinguished from patients with major depressive disorder.NURS 6670 : Mental Health Case Study

Bipolar I Disorder, Recurrent. The issues about defining the end of an episode of depression also apply to defining the end of an episode of mania. Manic episodes are considered distinct when they are separated by at least 2 months without significant symptoms of mania or hypomania.

Bipolar 11 Disorder

The diagnostic criteria for bipolar II disorder specify the particular severity, frequency, and duration of the hypomanic symptoms. The diagnostic criteria for a hypomanic episode are listed together with the criteria for bipolar II disorder (also in Table 8.1-6). The criteria have been established to decrease over diagnosis of hypomanic episodes and the incorrect classification of patients with major depressive disorder as patients with bipolar II disorder. Clinically, psychiatrists may find it difficult to distinguish euthymia from hypomania in a patient who has been chronically depressed for many months or years. As with bipolar I disorder, antidepressant-induced hypomanic episodes are not diagnostic of bipolar II disorder.

Specifiers (Symptom Features)

In addition to the severity, psychotic, and remission descriptions, additional symptom features (specifiers) can be used to describe patients with various mood disorders.

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With Psychotic Features.

The presence of psychotic features in major depressive disorder reflects severe disease and is a poor prognostic indicator. A review of the literature comparing psychotic with nonpsychotic major depressive disorder indicates that the two conditions may be distinct in their pathogenesis. One difference is that bipolar I disorder is more common in the families of probands with psychotic depression than in the families of probands with nonpsychotic depression.

The psychotic symptoms themselves are often categorized as either mood congruent, that is, in harmony with the mood disorder (“I deserve to be punished because I am so bad”), or mood incongruent, not in harmony with the mood disorder. Patients with mood disorder with mood-congruent psychoses have a psychotic type of mood disorder; however, patients with mood disorder with mood-incongruent psychotic symptoms may have schizoaffective disorder or schizophrenia.

The following factors have been associated with a poor prognosis for patients with mood disorders: long duration of

episodes, temporal dissociation between the mood disorder and the psychotic symptoms, and a poor premorbid history of social adjustment. The presence of psychotic features also has sig­ nificant treatment implications. These patients typically require antipsychotic drugs in addition to antidepressants or mood sta­ bilizers and may need ECT to obtain clinical improvement.

358 Chapter 8: Mood Disorders Table 8.1-6

DSM-5 Diagnostic Criteria for Bipolar I Disorder

For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes.

Manic Episode

A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospital­ ization is necessary).
During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
Inflated self-esteem or grandiosity.

Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
More talkative than usual or pressure to keep talking.
Flightofideasorsubjectiveexperiencethatthoughtsareracing.
Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal directed activity).
Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)NURS 6670 : Mental Health Case Study

The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or there are psy­ chotic features.
Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but per­ sists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and therefore a bipolar I disorder.

Note: Criteria A to D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder

Hypomanic Episode

A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree:
Inflated self-esteem or grandiosity.

Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
More talkative than usual or pressure to keep talking. Flightofideasorsubjectiveexperiencethatthoughtsareracing.
Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.

Increase in goal-oriented activity (either socially, at work or school, or sexually) or psychomotor agitation.
Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symp­ tomatic.
The disturbance in mood and the change in functioning are observable by others.
The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitaliza­ 
tion. If there are psychotic features, the episode is, by definition, manic.
The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment).NURS 6670 : Mental Health Case Study
Note: A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indica­ tive of a bipolar diathesis.

Note: Criteria A to F constitute a hypomanic episode. Hypomanic episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.

Major Depressive Episode

Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previ­ ous functioning; at least one of the symptoms is either (1 ) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to another medical condition.
1 . Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless)

or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)

Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by 
either subjective account or observation)
Significant weight loss when not dieting or weight gain (e.g., a change of more than 5°/o of body weight in a month) or 
decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
Insomnia or hypersomnia nearly every day.
Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings or restlessness or being slowed down).
Fatigue or loss of energy nearly every day.
Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self­ reproach or guilt about being sick).
Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or another medical condition.
Note: Criteria A to C constitute a major depressive episode. Major depressive episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.

Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness
or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or consid­ ered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individu­ al’s history and the cultural norms for the expression of distress in the context of loss.1

1 In distinguishing grief from a major depressive episode (MOE), it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in MOE it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of MOE is more persistent and not tied to specific thoughts or preoccupations. The pain or grief may be accompa­ nied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of a major depressive episode.NURS 6670 : Mental Health Case Study

The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than a self-critical or pessimistic ruminations seen in a MOE. In grief, self-esteem is generally preserved, whereas in MOE, feelings of worthlessness and self-loathing
are common. If self-derogatory ideation is present in grief, it typically involves perceived failings vis-a-vis the deceased (e.g., not visiting frequently enough, not tell ing the deceased how much he or she was loved). If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly “joining” the deceased, whereas in a major depressive episode such thoughts are focused on ending one’s own

life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.

Bipolar I Disorder

Criteria have been met for at least one manic episode (Criteria A to D under “Manic Episode above).
B. The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia,
schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

Coding and Recording Procedures

The diagnostic code for bipolar disorder is based on type of current or most recent episode and its status with respect to current severity, presence of psychotic features, and remission status. Current severity and psychotic features are only indicated if full criteria are currently met for a manic or major depressive episode. Remission specifiers are only indicated if the full criteria are not currently met for a manic, hypomanic, or major depressive episode. Codes are as follows:

8.1 Major Depression and Bipolar Disorder 359

NURS 6670 : Mental Health Case Study

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