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