Download List of Symptoms Mood swings from elation to depression Periods of

List of Symptoms

Mood swings from elation to depression

Periods of mania, lasting for several days, with decreased need for sleep,
increased creativity, productivity, and sexual urges

Psychotic episode with current manic period

Grandiose and inflated sense of self-esteem during manic periods

Extensive periods of depression, often lasting two weeks

Catatonia sometimes present during periods of depression

Symptoms interfere with social and occupational functioning

Violent and agitated outburst in ER at hospital
Symptoms in Relation to Chart of Emotional Disorders (DSM-IV-TR)
Axis I
Symptomatic
Anxiety
Mood
Thought
Sleep
Acute Stress
Bipolar
Schizophrenia
Sexual
PTSD
Major Depression
Delusional
Psychotic
Diagnostic Considerations for Carla
1. Major Depressive Disorder With Psychotic Episode 296.xx
Carla was diagnosed with Major Depressive Disorder after her depression in high
school. As described in DSM-IV-TR, Major Depressive Disorder is characterized by
one or more Major Depressive Episodes (which certainly describes Carla), but
without a history of Manic, Mixed or Hypomanic Episodes. Because Carla does not
meet Criteria A and C, the original diagnosis that was given to her during her
depression in boarding school is not accurate. In the Differential Diagnosis discussion
of Major Depressive Disorder, the clue to Carla’s correct diagnosis is found: “The
presence of Manic or Mixed Episodes (with or without Hypomanic Episodes)
indicates a diagnosis of Bipolar I Disorder” (DSM-IV-TR, p. 373).
2. Acute Stress Disorder 308.3
Although it does not appear that Carla meets all the criteria for Acute Stress Disorder,
particularly with the absence of anxiety and dissociative symptoms, it might bear
more investigation into her earlier symptoms to see if there is any possibility of Acute
Stress Disorder and/or Post-Traumatic Stress Disorder. Through the letter from her
brother, she has been exposed to a stressor that involves that involves “direct personal
experience of an event that involves actual or threatened death or serious injury . . . or
a threat to the physical integrity of another person” (DSM-IV-TR, p. 463). And in the
case of Acute Stress Disorder, if the disturbance continues for more than 4 weeks, the
diagnosis of Post-Traumatic Stress Disorder may be applied (DSM-IV-TR, p. 469).
2. Bipolar I Disorder, Severe With Psychotic Features 296.4
With Carla’s consistently shifting mood swings from elation to depression, this
diagnosis should be considered as a replacement diagnosis for the Major Depressive
Disorder that she originally received. One caveat to consider is that Carla’s
antidepressant medication could be contributing to the mania, as described in the
DSM-IV-TR Differential Diagnosis on Bipolar I Disorder:
“Symptoms like those seen in a Manic or Mixed Episode may also be precipitated
by antidepressant treatment such as medication, electroconvulsive therapy or light
therapy. Such episodes may be diagnosed as a Substance-Induced Mood Disorder
(e.g., Amitriptyline-Induced Mood Disorder, with Manic Features;
Electroconvulsive Therapy-Induced Mood Disorder, With Manic Features) and
would not count toward a diagnosis of Bipolar I Disorder. However, when the
substance use or medication is judged not to fully account for the episode (e.g.,
the episode continues for a considerable period autonomously after the substance
is discontinued), the episode would count toward a diagnosis of Bipolar I
Disorder” (DSM-IV-TR, p. 387). With the presence of at least one Manic or Mixed
Episode (which Zara confirms), we can diagnose Bipolar I Disorder instead of
Major Depressive Disorder and Dysthymic Disorder. According to DSM-IV-TR,
“Bipolar I Disorder is distinguished from Bipolar II Disorder by the presence of
one or more Manic or Mixed Episodes” (DSM-IV-TR, p. 387).
3. Schizophrenia, Undifferentiated Type 295.90
With Carla’s sudden psychotic episode, the question of Schizophrenia or another
thought disorder must be considered. It is possible that receiving a letter from her
brother could trigger an onset of a Schizoaffective Disorder, Schizophrenia, or a
Delusional Disorder. However, there is no gradual onset of symptoms as is the
usual course in this disorders, and Carla’s delusions and schizophrenic-like
behaviors, together with the total picture of her symptoms, can be better
accounted for in other disorders, such as Bipolar I Disorder/Severe With
Psychotic Episode or Major Depressive Episode With Psychotic Symptoms.
DSM-IV-TR elucidates the distinction here between thought disorders and bipolar
disorders:
“The differential diagnosis between Psychotic Disorders (e.g., Schizoaffective
Disorders, Schizophrenia, and Delusional Disorder) and Bipolar I Disorder may
be difficult (especially in adolescents) because these disorders may share a
number of presenting symptoms (e.g., grandiose and persecutory delusions,
irritability, agitation, and catatonic symptoms), particularly cross-sectionally and
early in their course. In contrast to Bipolar I Disorder, Schizophrenia,
Schizoaffective Disorder, and Delusional Disorder are all characterized by periods
of psychotic symptoms that occur in the absence of prominent mood symptoms.
Other helpful considerations include the accompanying symptoms, previous
course, and family history. Manic and depressive symptoms may be present
during Schizophrenia, Delusional Disorder, and Psychotic Disorder Not
Otherwise Specified, but rarely with a sufficient number, duration, and
pervasiveness to meet criteria for a manic Episode or a Major Depressive
Episode. However, when full criteria are met (or the symptoms are of a particular
clinical significance), a diagnosis of Bipolar Disorder Not Otherwise Specified
maybe be made in addition to the diagnosis of Schizophrenia, Delusional
Disorder, or Psychotic Disorder Not Otherwise Specified. If there is a very rapid
alternation (over days) between manic symptoms and depressive symptoms (e.g.,
several days of purely manic symptoms followed by several days of purely
depressive symptoms) that do not meet minimal duration criteria for a Manic
Episode or Major Depressive Episode, the diagnosis is Bipolar Disorder Not
Otherwise Specified” (DSM-IV-TR, p. 387).
Discussion of Diagnosis
After careful observation and evaluation and ruling out a medication-induced disorder
(see discussion above in Bipolar I diagnostic category), Carla appears to be suffering
from Bipolar I Disorder, Most Recent Episode Manic/Severe With Psychotic Features.
She meets the following criteria:

Currently in a Manic Episode

Has had a least one Major Depressive Episode previously
o Depressed mood most of the day, nearly every day
o Markedly diminished interest or pleasure in daily activities
o Insomnia or hypersomnia every day
o Psychomotor retardation observed by others
o Fatigue or loss of energy nearly every day
o Diminished ability to think or concentrate
o The above symptoms cause clinically significant impairment or distress in
social, occupational, or other important areas of functioning.

Mood Episodes in Criteria A and B are not better met by Schizoaffective Disorder
and are not superimpose on Schizophrenia, Schizophreniform Disorder,
Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
Full criteria are met for a Manic Episode, which Severe With Psychotic Features. More
observation and evaluation of Carla is needed to determine what criteria she meets for the
longitudinal course specifiers that apply to mood disorders (see p. 424, DSM-IV-TR). The
extensive discussion of Bipolar Disorders in DSM-V provided me with additional
guidelines and considerations in Carla’s diagnosis.
DSM-IV Multiaxial Evaluation
Axis I
296.44
Bipolar I Disorder, Most Recent Episode/Severe
With Psychotic Features
Axis II
V71.09
No Diagnosis
Axis III
No known medical conditions
Axis IV
Stressor of repeated sexual abuse by family member at early age; raped at
age 19. Disinherited and disowned by repressive family after disclosing
abuse. Lack of educational or occupational outlet for intellectual and
artistic abilities.
Axis V
GAF: 25
Diagnosis According to DSM-5
296.44 (F31.2) Bipolar I Disorder, Manic, With Psychotic Features
NICELY DONE DIAGNOSTIC SECTION
Evidence-Based Treatments from The Complete Adult Psychotherapy
TREATMENT PLANNER, 4th edition
Disorder
Short-Term Goals
Major Depressive
Disorder With
Psychotic Episode
Thorough
assessment;
medication if
needed; suicide
prevention
measures; rule out
organic cause
Acute Stress
Disorder
Thorough
Assessment;
Long-Term Goals
Selected
Therapeutic
Treatments
Alleviate depressed Work with client to
mood and return to
recognize
previous level of
depressors; develop
functioning; develop awareness of
skills to prevent
automatic thoughts;
relapse;
assign daily journal;
appropriately grieve cognitive-behavioral
work; exercise
program; explore
experiences from
childhood and
express repressed
feelings
Reduce negative
Establish rapport
impact and return to while gently
verbalization of
event and symptoms
Post-Traumatic
Stress Disorder
Thorough
Assessment;
verbalization of
event and symptoms
Schizophrenia
Describe type and
history of
symptoms; family
history; assess
client’s thought
disorder (brief or
long-term)
Bipolar I Disorder
NOTE: There are no
EBTs listed
specifically for
Bipolar Disorder
pre-trauma level of
functioning; develop
coping skills,
terminate
destructive
behaviors and
implement healing
behaviors
exploring facts of
trauma; assess
medication needs;
discuss PTSD;
reading, cognitive
therapy;
combination of
homework and work
in therapy to
desensitize patient
to trauma
Reduce negative
Establish rapport
impact and return to while gently
pre-trauma level of
exploring facts of
functioning; develop trauma; assess
coping skills,
medication needs;
terminate
discuss PTSD;
destructive
reading, cognitive
behaviors and
therapy;
implement healing
combination of
behaviors
homework and work
in therapy to
desensitize patient
to trauma
Control or eliminate Calm nurturing
active symptoms
manner, good eye
and return to normal contact and active
functioning; focus
listening; alleviate
thoughts on reality
client’s fears and
reduce feelings of
alienation; family
therapy sessions;
monitor medication;
refer family for
support
Medication Table for Various Disorders from:
National Institute of Mental Health: Introduction: Mental Health Medications,
National Institute of Mental Health website
Condition
Newer Medication
Major Depressive
Disorder
Selective Serotonin
Reuptake Inhibitors
(SSRIs)
Acute Stress
Disorder
Antidepressants or
anti-anxiety
medications,
depending on
specific symptoms
Antidepressants or
anti-anxiety
medications,
depending on
specific symptoms
Mood stabilizers,
accompanied
sometimes by
antipsychotic and
antidepressants
Antipsychotic
medications (typical
and atypical)
Post-Traumatic
Stress Disorder
Bipolar Disorder
Schizophrenia
Alternative
Medication
Serotonin and
Norepinephrine
Reuptake Inhibitors
(SNRIs)
Older Medication
Tricyclics,
Tetracyclics, and
Monoamine
Oxidase Inhibitors
(MAOIs)
How is diagnosis harmful or helpful?
Carla’s case illustrates some of the pitfalls of a psychiatric diagnosis. Initially, her early
diagnosis of Major Depressive Disorder was harmful because she was not being treated
with the correct medications. Somehow the symptoms she exhibited during her manic
periods were not recognized. She also received inadequate treatment to address the
trauma that she suffered as a result of prolonged sexual abuse and a childhood of
emotional and psychological neglect.
The shock of suddenly being diagnosed with bipolar disorder could be harmful to
Carla, who has had many challenges in her life. She will have to integrate a new way of
looking at herself as she tries to recover from her manic episode.
Treatment Plan
Medical Intervention
In treating Carla, the first step is to stabilize her sleep and try to bring her out of her
psychosis. The first intervention, the medical treatment by the hospital psychiatrist, has
already occurred in Carla’s case when she was physically restrained and treated with an
antipsychotic drug. (Note: Although this is not the forum for a discussion about the
appropriate use of physical and chemical restraints in psychiatric settings, this is an
important topic in terms of striking the balance between doing least harm to the patient
and maintaining a safe environment for the staff. The American Psychiatric Nurses
Association has an interesting position paper on the topic: See References) GOOD
POINT. Carla will need to be evaluated to see what harm might have occurred as a result
of the restraint procedures. The next step is a careful re-evaluation of her medication
history to see whether any of the antidepressant medications she has been taking have
been effective and how this might have affected her current psychotic episode.
With the diagnosis of Bipolar I Disorder, Carla will need to be slowly and
carefully weaned off her antidepressant medications and placed on a mood stabilizer. She
might need to be placed on more than one medication, which could include the use of an
antidepressant and antipsychotic. It is most important that she receives ongoing and
involved treatment from a competent and experienced psychiatrist and not simply quick
medical checks every six weeks.
Building on Carla’s Strengths
The first step in tapping into Carla’s considerable resilience will be interacting with
supportive adults. Ideally, Carla’s treatment will be integrated with a group of health care
professionals that have a team approach to keeping Carla safe and supported as she
begins to rebuild her life. YES This begins with her therapist, whether it is an expressive
arts therapist, a psychologist or psychiatrist, a family therapist or some other health
professional. Building a therapeutic alliance, addressing and resolving some of the core
issues from her childhood and years of abuse, acclimating herself to her new diagnosis
and the way that she operates in the world, and building on her strengths is my basic
treatment plan for Carla. This can be implemented using a variety of interventions.NICE
Inpatient Group Therapy
As Carla progresses, I would recommend that she join a group of patients also diagnosed
with bipolar disorder. One of the most powerful moments in the video about bipolar
disorder, “Four Voices,” was watching the reactions of the people when they were able to
talk with people who had a similar condition. Their eyes lit up in recognition and joy
from the seemingly simple step of meeting with other people who have bipolar disorder. I
think this could be a powerful and healing experience for Carla. YES!
Expressive Arts Therapy
Given Carla’s interest in art and creative pursuits, using an expressive arts therapist for
ongoing therapeutic intervention could be very effective. For example, an art therapist
could work with Carla to make a mask that shows the different sides of her behavior or
personality during her bipolar episodes. With Carla’s interest in human anatomy, this
could be an exercise done over a period of sessions. Full-body maps and intricate work in
this regard to “rebuild” Carla’s sense of self after being diagnosed with bipolar could also
alleviate some of her symptomatic distress.
A dance or drama therapist might also be very helpful as Carla addresses some of
the issues surrounding her family and sexual abuse; it would also help to discharge some
of her manic energy. Keeping her safe in a supportive environment is paramount for
every professional that she works with. Another avenue for Carla in the expressive
therapies is writing therapy. As I discussed in my midterm, the work done by Pennebaker
(1997) shows how disclosing trauma in written form can have both psychological and
physiological benefits. Instead of writing on her body, she could write in a journal or
record a video or take photographs to record her “creative ideas.”
In her article on resilience, Butler discusses how the special hobbies of the Kauai children
started a “a positive chain reaction: their hobbies taught them competence and mastery,
gave them a place to be other than at home and helped them continue to recruit
supportive adults outside their nuclear families” (Butler, 1997, no page number).
Although the primary focus of expressive therapies is the therapy, building Carla’s
artistic confidence could be a positive side effect of the therapy that might bring help to
further develop her skills and talents to pursue occupational goals that are best suited to
her abilities and disposition. For example, she might investigate becoming a medical
illustrator or some form of health professional. Giving Carla some sense of hope in her
future