To prepare for this Assignment:

• Select an adult or older adult client with a bipolar disorder that you have seen in your practicum.

In 3-4 pages, write a treatment plan for your client. In which you do the following:

• Describe the HPI and clinical impression for the client. 
• Recommend psychopharmacologic treatments and describe specific and therapeutic end points for your psychopharmacologic 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.

To prepare for this Assignment:

Select an adult or older adult client with a bipolar disorder that you have seen in your practicum.

In 3-4 pages, write a treatment plan for your client. In which you do the following:

Describe the HPI and clinical impression for the client. 
Recommend psychopharmacologic treatments and describe specific and therapeutic end points for your psychopharmacologic 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.

1

bipolar disorder 8

Captain of the Ship: Bipolar Disorder

The following case study details the treatment approach for a 35-year-old Caucasian male who presented to the clinic for help with his mood disorder. The assessment and intake supported the diagnosis of bipolar disorder, subtype II. The following analysis presents the details related to both pharmacology and psychotherapy, as well as information related to medical management, community support resources, and appropriate follow-up.

Chief Complaint

The client came to the clinic reporting that he “could no longer deal with his up-and-down mood swings and that he was at the end of his rope.”

History of Presenting Problem

This client stated that he has had mood swings for as long as he could remember, and that right now he was in the “up” phase of this alternating mood pendulum. From an inspection of the genogram that the client provided, there was a noticeable inheritance pattern of the bipolar. Notably, this client had evidence of bipolar on both maternal and paternal sides of his genogram. Research has shown that bipolar has a high heritability rate. Kern (2014) reported on the concordance rates of twins with bipolar, stating the rate was from 60-80%. In other studies, the heritability of bipolar is demonstrated albeit at lower rates (Maier et al. (2005).

The DSM-V characterizes bipolar II disorder as one in which individuals experience a period of at least 4 days of hypomanic symptoms; once this criterion is met, the person fits the diagnosis of bipolar II regardless of the duration of future hypomanic episodes (APA, 2013). Additional symptoms to support this diagnosis were the client’s admission that he was taking on several projects and tasks at work simultaneously; sleeping little; experiencing racing thoughts; and feeling invincible. The intake showed the client’s extremely fast talking, switching subjects haphazardly, and admission of both depressive and hypomanic episodes, all of which point to a diagnosis of bipolar II (296.89 F31.81) (APA, 2013).

Current Medications

This client denied taking any medications, either over the counter or from a doctor. Although he claimed he was in good health, he did report that he frequently got headaches but not of migraine proportions. He described them as more of an annoyance than a health problem. He gained relief from either Motrin or Tylenol during these headache episodes. He denied taking any vitamins or herbs or any other OTC substances.

Relevant History

The client reported that his mood swings began when he was in his early 20s. As he witnessed other family members suffering from these mood swings, he came to believe they were normal. The client appeared to be in good health, was not overweight, and appeared to take good care of himself. He was dressed well and was oriented x4. He stated that he earned a good living working as a financial consultant, enjoyed his work, but could not deal with the revolving mood swings anymore. His purpose for coming to the clinic was get help for this apparent mood disorder.

Diagnostic Impression

As stated, the client’s symptomatology and relevant history align with a diagnosis of bipolar disorder, subtype II. Running along a continuum from mild to severe, this disorder is saliently circumscribed by the major depressive phase alternating with the hypomanic phase (Antokhin et al., 2010; APA, 2013). The DSM-V clearly states that the bipolar II diagnosis is confirmed by individuals’ experience with at least one episode of major depression and at least one hypomanic episode (APA, 2013; Samalin et al., 2016). Because the client has never experienced a full-blown mania, so typical of the bipolar I subtype, the diagnosis is best supported by the criteria of the bipolar II subtype.

Psychopharmacology and End Points

Both subtypes of bipolar can be extremely debilitating to individuals who suffer from these illnesses. For one, this client reported regular sleep disturbances and an omnivorous appetite for increased responsibilities at work, the result of which could be extreme overwhelm. Sadock et al. (2014) described such overwhelm, stating that bipolar individuals often experienced extreme emotional distress because of such unrelenting task assumption. The typical treatment for bipolar patients and one directed at mood stabilization is lithium therapy (Stahl, 2013). The recommended regimen based on all the information for this case would be 600mg of a lithium salt TID. Ward (2017) reported on the efficacy of this treatment to target the up-and-down nature of the disorder. During lithium therapy, clients must have their blood monitored regularly to ensure that the target of 1-1.5mEq/L blood serum levels is established (Sadock et al., 2014). Supplemental pharmacology might include the drugs venlafaxine and olanzapine, the first an antidepressant and the second an antipsychotic (Stahl, 2013). These meds would help with any psychotic episodes that the client might experience (Sadock et al., 2014). To avoid overprescribing of psychotropics, no adjutant therapy would commence until the results of lithium therapy have been established. The therapeutic endpoint would be improvement in the client’s mood swings over the ensuing weeks after initiation of pharmacology.

Psychotherapy and End Points

The gold standard of psychotherapy is cognitive behavioral therapy (CBT) and will be recommended on a weekly basis. The literature is replete with research supporting the efficacy of CBT in bipolar cases (Jones et al., 2012; Sadock et al., 2014). Gabbard (2014) reported that bipolar patients who attended regular CBT therapy enjoyed welcome relief from the nefarious symptoms of the illness. But as with other mental health disorders, bipolar is best treated with a multimodal approach. Antokhin et al. (2010) discussed the benefits of sociotherapy to complement modalities like CBT and other group behavioral therapies. The endpoint of psychotherapy would be to restore normal functioning to the client, as much as is realistically possible, and see him begin to be less hampered by the disorder, especially insofar as his sleep disturbance and feelings of invincibility.

Medical Management and Follow-Up

Importantly, lithium therapy can be dangerous if blood levels rise to 2.5mEq/L (Sadock et al., 2014). For this reason, the client will be sent for regular blood draws to ensure levels remain within the safe zone. Moreover, the client will be enjoined to see his regular doctor for routine vaccinations and other preventive routine diagnostic tests. The client will be educated on the important side effects of pharmacology. Notably, lithium can produce side effects of diarrhea, muscle fatigue, and shaky gait (Stahl, 2013). The client will be advised to notify his doctor immediately of any of these problems and to report to the nearest hospital for emergency care.

Support Resources

The National Alliance on Mental Illness (NAMI) offers a wide range of social support services through its website and national hotline. These services encompass everything from a suicide hotline to help finding a mental health specialist to books and other printed materials on bipolar (NAMI, 2018). Another online resource is the Depression and Bipolar Support Alliance (DBSA), which offers abundant information on bipolar and related mood disorders (DBSA, 2020). The FAIR START program helps persons with bipolar to find expert clinical research on the disorder (FAIRSTART, 2019). This program is run by Stanford Medical School and offers help for bipolar individuals to get evaluated properly and find appropriate treatment.

References

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). APA.

Antokhin, E., Bardyurkina, V., Budza, V., Kryukova, E., & Baldina, O. (2010). Bipolar depression of the II type: Psychopathology, therapy. European Psychiatry, 25.

Depression and Bipolar Support Alliance (DBSA). (2020).

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FAIR START. (2019). From affective illness to recovery: Student access to rapid treatment (FAIR START). Stanford Medicine. http://med.stanford.edu/bipolar/Fairstart.html

Gabbard, G. O. (2014). Gabbard’s treatment of psychiatric disorders (5th ed.). American Psychiatric Publications.

Jones, S., Mulligan, L. D., Law, H., Dunn, G., Welford, M., Smith, G., & Morrison, A. P. (2012). A randomized controlled trial of recovery focused CBT for individuals with early bipolar disorder. BMC Psychiatry, 12: 204.

Kerner, B. (2014). Genetics of bipolar disorder. Applied Clinical Genetics, 7: 33-42.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3966627/

Maier, W., Höfgen, B., Zobel, A., & Rietschel, M. (2005). Genetic models of schizophrenia and bipolar disorder: overlapping inheritance or discrete genotypes? European Archives of Psychiatry and Clinical Neuroscience, 255(3), 159–166.

National Alliance on Mental Illness (NAMI). (2018). Retrieved June 30, 2020 from

Homepage

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

Samalin, L., de Chazeron, I., Vieta, E., Bellivier, F., & Llorca, P. (2016). Residual symptoms and specific functional impairments in euthymic patients with bipolar disorder. Bipolar Disorders, 18(2), 164–173.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). Cambridge University Press.

Ward, I. (2017). Pharmacologic options for bipolar disorder. Clinical Advisor, 20(3), 17–25.