Case Study Of Bipolar Disorder
Primary Diagnosis
The primary diagnosis of this case is type 1 bipolar disorder. Type 1 bipolar disorder is characterized by at least one episode of mania, hypomanic or major depressive episodes may occur but are not required for diagnosis. According to DSM-5 (2013), mania is characterized by persistently elevated mood most of the day for at least 7 days with features such as pressured speech, psychomotor agitation, increased goal-directed activity, excessive involvement in risky activities such as compulsive shopping, decreased need for sleep, distractibility and grandiosity. Additionally, these symptoms have impaired her functioning and are not attributable to any other medical or psychiatric condition. Case Study Of Bipolar Disorder
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Medications
Severe bipolar disorder or bipolar disorder resistant to lithium monotherapy may be treated with a combination of another mood stabilizer and an antipsychotic. Atypical antipsychotics such as quetiapine, risperidone, aripiprazole, and olanzapine can be used since they have a relatively safer adverse effect profile compared to typical antipsychotics such as haloperidol. Similarly, she has psychotic episodes (Chokhawala & Stevens, 2022). Black box warnings for atypical antipsychotics include an increased risk of death and cerebrovascular events in dementia (Chokhawala & Stevens, 2022). However, this should be used in combination with sodium valproate, an alternative mood stabilizer that is effective for the treatment of manic episodes associated with bipolar disorder (Rahman & Nguyen, 2022). Black box warnings for sodium valproate include hepatotoxicity, fetal risk, and pancreatitis (Rahman & Nguyen, 2022).
Cognitive-behavioral therapy is an effective nonpharmacological intervention for individuals with bipolar disorder and therefore must be considered. This therapy reduces the suicide risk associated with bipolar disorder. However, it should be used in combination with pharmacotherapy. Long-term management with this modality is associated with improved social function, decreased relapse rates, and diminished need for pharmacotherapy (Bryan, 2019)Case Study Of Bipolar Disorder.
Inpatient treatment of her condition ensures medication adherence and minimizes harm to the patient and others. These are attributable to the reduction of external stimuli, and the resolution of mania and psychosis. Several blood tests are required to detect conditions that may impact management and rule out differential diagnoses. These include lipid profile, random blood sugar, liver function tests, urea, creatinine, and electrolytes to establish a baseline before long-term pharmacologic management. Similarly, complete blood count (to rule out anemia), TFTs (rule out thyroid disease), urinalysis, urine toxicology screen, and pregnancy tests are required. Finally, ECG is mandatory to identify QT interval prolongation and other heart conditions that may be aggravated by valproate and antipsychotics.
Suicide Risk
The suicide assessment five-step step evaluation and triage (SAFE-T Pocket Card) for clinicians encompass the five components of suicide assessment including identification of risk and protective factors, conducting an inquiry about suicidality, selecting an appropriate intervention, and documentation of the process and a follow-up plan (Stevens et al., 2021)Case Study Of Bipolar Disorder. Risk factors for suicide include previous suicide attempts, psychiatric disorders, male sex, socioeconomic status, access to firearms, history of sexual assault, history of aggressive behaviors, and other serious diseases. Protective factors for suicide include problem-solving skills, connection to friends, availability of mental and physical care, limited access to lethal means, cultural and religious support as well as supportive relationships. Treatment includes dialectical behavioral therapy, CBT, restricting access to lethal means, and safety planning. All patients should be followed up. Finally, additional questions to ask her include; family member that died by suicide, history of sexual assault, and social support, her relationships, any psychiatric hospitalizations, alcohol or substance use, and any serious diseases such as cancer.
References
Bryan, C. J. (2019). Cognitive behavioral therapy for suicide prevention (CBT-SP): Implications for meeting standard of care expectations with suicidal patients. Behavioral Sciences & the Law, 37(3), 247–258. https://doi.org/10.1002/bsl.2411
Chokhawala, K., & Stevens, L. (2022). Antipsychotic Medications. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519503/
DSM-5. (2013). Psychiatry.org. https://psychiatry.org/psychiatrists/practice/dsm
Rahman, M., & Nguyen, H. (2022). Valproic Acid. https://pubmed.ncbi.nlm.nih.gov/32644538/
Stevens, K., Thambinathan, V., Hollenberg, E., Inglis, F., Johnson, A., Levinson, A., Salman, S., Cardinale, L., Lo, B., Shi, J., Wiljer, D., Korczak, D. J., & Cleverley, K. (2021). Core components and strategies for suicide and risk management protocols in mental health research: a scoping review. BMC Psychiatry, 21(1), 13. https://doi.org/10.1186/s12888-020-03005-0 Case Study Of Bipolar Disorder
Trazodone
Trazodone for sleep disorders is associated with several side effects that must be included in patient education including suicidal thoughts, drowsiness, blurring of vision, dry mouth, nausea and vomiting, diarrhea, hypotension, dizziness, headaches, tremors, skin rashes, and priapism among others. Cardiac effects of trazodone include hypotension, arrhythmias, QT interval prolongation, tachycardia, palpitations, chest pain, and hypertension (Shin & Saadabadi, 2022). Trazodone is known to cause renal and hepatic impairment. Consequently, baseline tests such as complete blood count, urea, creatinine, and electrolytes as well as liver function tests are essential.
When prescribing SSRIs/SNRIs to a patient, it is vital to warn the patient of increased suicidal thinking, behavior, and feeling which is regarded as a black-box warning by the FDA. Similarly, patients must be told that it takes about 4 to 6 weeks of therapy to achieve full antidepressant effect although 1 to 4 weeks of therapy is required for the onset of antidepressant effect. Organic disorders may also manifest with depressive symptoms. Therefore, laboratory tests such as thyroid function tests, urinalysis, complete metabolic panel, vitamin D levels, and urine toxicology are required to rule out these causes (Kim, 2020).
Differential diagnoses for depressive disorders include depressive disorder due to another medical condition, grief, adjustment disorder, substance/medication-induced depressive disorder, disruptive mood dysregulation disorder, and burnout syndrome (Kim, 2020). Major depression disorder is usually a clinical diagnosis based on the DSM 5 criteria (Kim, 2020). However, Patient health questionnaire 9 and Beck Depression Inventory are questionnaires that aid in determining features of depression. Additionally, patient health questionnaire-2 may be used for screening of this condition. All patients must be assessed for suicidal risk. Antidepressants are the principal medications for treating major depressive disorders because they increase serotonin and norepinephrine levels. Other treatment modalities include psychotherapy (CBT, interpersonal therapy, family and couples therapy, and psychodynamic therapy), sleep hygiene, light therapy, aerobic exercise, nutrition, and social support (Karrouri et al., 2021). Finally, repetitive transcranial magnetic stimulation and electroconvulsive therapy are reserved for severe, refractory, and psychotic depression.
References
Karrouri, R., Hammani, Z., Benjelloun, R., & Otheman, Y. (2021). Major depressive disorder: Validated treatments and future challenges. World Journal of Clinical Cases, 9(31), 9350–9367. https://doi.org/10.12998/wjcc.v9.i31.9350
Kim, Y.-K. (2020). Major depressive disorder: Current advances and paradigm shifts. Psychiatry Investigation, 17(3), 179–180. https://doi.org/10.30773/pi.2019.0092
Shin, J. J., & Saadabadi, A. (2022). Trazodone. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470560/
