Review the case study of Ellen. Come up with a DSM diagnosis based on the inform

Question

Review the case study of Ellen. Come up with a DSM diagnosis based on the information provided, as well as a treatment plan to touch on all of the issues this client expressed. Use the following webpage link to access DSM diagnostic categories and their criteria.

Case Study: Ellen Smalls

Ellen Water’s psychotherapist referred her for a medication consultation because of her continuing depressed mood and panic attacks. She is a 37-year-old part-time graduate student who lives alone and supports herself by working as a home health aide. She completed the course work for a Ph.D. in psychology 3 years ago, but has not yet begun her dissertation.

            Ellen is indeed an unhappy-looking woman and describes being unhappy through much of her life, with no long periods of feeling really good. Her father had a history of alcohol problems, and there was always a great deal of strife in her parents’ marriage. She denies sexual or physical abuse, but feels that her parents were “emotionally abusive” to her. She was first referred for treatment after she made a suicide attempt at age 14, and there have been many times over the years during which her usual low-level depression has become considerably worse, but she has not sought treatment.

            Two years ago, when she had been seeing her current boyfriend for about 4 years, it finally became clear that he was unwilling to marry her or live with her. She began to get more depressed and to experience acute panic attacks, and it was at that time that she entered psychotherapy.

            In the month before consultation, she says she was depressed most of the time. She gained about 10 pounds because she was constantly nibbling on chips or cookies or making herself peanut butter sandwiches. She often awakened in the middle of the night, was unable to go back to sleep for hours, and then overslept the following day, often sleeping up to 18 hours. She says she feels like dead weight, her legs and arms are heavy, and she is always tired. She ruminates about her own failures and cannot concentrate on any serious reading. Although she often wishes to be dead, she has not made any recent suicide attempts.

            Ellen’s academic and vocational history have been erratic. She has a master’s degree in psychology and worked as a counselor for a while, but found this too upsetting. She then began a Ph.D.program in psychology, completed her course work, but interrupted this to train in physical therapy. She has never worked in one job for more than a few years and has sent much of her adult life as a student.

Her current romance is the longest she has sustained. She lived with a man once previously, but this was a brief and tumultuous relationship. Boyfriends have described her as “needy and clinging.”And it appears her current boyfriend fears her neediness.

            Although Ellen reports chronic depression, when she is asked about “high” periods, she describes many episodes of abnormally elevated mood that have lasted for several months. During these times she would function on 4 or 5 hours of sleep a night, run up huge telephone bills, and feel that her thoughts were racing. She was able to get a lot done, but her friends were obviously concerned about the change in her behavior, urging her to “slow down” and “calm down.” She has never gotten into any real trouble during these episodes.

Explanation / Answer

Ellen's current diagnosis will be that of Bipolar Disorder. She has entered a stage where she now has bouts of manic episodes. Given below is the diagnosis of Bipolar Disorder from the DSM, 4th Edition, Text-Revision. It is the current criteria for Bipolar Disorder I, II and NOS.

DSM-IV Criteria for a Major Depressive Episode

According to the DSM-IV, the diagnostic criteria and symptoms of a major depressive episode are the same both in Bipolar and Unipolar disorders.

A. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad or empty) or observation made by others (e.g. appears tearful)

2. 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 made by others)

3. Significant weight loss when not dieting or weight gain (e.g. a change of more than 5% of body weight in a month), or decrease or increase in the appetite nearly every day

4. Insomnia or hypersomnia nearly every day

5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

6. Fatigue or loss of energy nearly every day

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

9. 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

B. The symptoms do not meet criteria for a Mixed episode

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g. hypothyroidism)

E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

DSM-IV Criteria for a Manic / Hypomanic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary)

B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree

1. Inflated self-esteem or grandiosity

2. Decreased need for sleep (e.g. feels rested after only three hours of sleep)

3. More talkative than usual or pressure to keep talking

4. Flight of ideas or subjective experience that thoughts are racing

5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The symptoms do not meet criteria for a Mixed Episode

D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or other, or there are psychotic features

E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g. hyperthyroidism)

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count towards a diagnosis of Bipolar I disorder

1.3.1.2 Criteria for a Hypomanic Episode

Here it is more interesting to note the similarities and differences between the hypomanic episode and the manic one, rather than to reproduce the criteria. To start with the similarities, both a hypomanic and a manic episode share the same key diagnostic symptoms (A: elevated-expansive-irritable mood and B: 3 or 4 manic symptoms out of 7 identified). Also, similarly to the manic episode, the causation of the hypomanic episode cannot be due to substance use or a general medical condition.

But what really differentiates the two episodes or states from each other, is the severity, duration, and from a psychological point of view the experience of each patient. The DSM-IV sets four days as the minimum duration for a hypomanic episode and states that the mood has to be “clearly different from the usual non-depressed mood”. But the two most important criteria (D and E) that refer to functional impairment essentially summaries the major difference between a hypomanic and a manic episode. The hypomanic episode is associated with an “unequivocal change in functioning that is uncharacteristic of the person when not symptomatic” (criterion C of hypomanic episode) and “the episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features” (criterion D).

DSM-IV Criteria for a Mixed Episode

A. The criteria are met both for a Manic Episode and for a Major depressive episode (except for duration) nearly every day during at least a 1-week period

B. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features

C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g. hyperthyroidism).

For all four of these episodes, the symptoms must have an impact on the person’s ability to function and can’t derive from some other circumstance or illness that would logically, or better, account for its expression.

Bipolar I and II; The Difference

Based on the above episodes, the DSM-IV identifies only two primary bipolar sub-types / diagnoses. Bipolar I disorder, which is also considered the classic presentation of Bipolar illness, and Bipolar II disorder, often mistakenly considered a less severe presentation of the disorder. The different episodes serve as building blocks for reaching either a bipolar I or a bipolar II diagnosis. The main difference between BP I and BP II is full mania (7 days) v. hypomania (4 days). Once a person experiences a full manic episode, they will receive a BP I diagnosis.

A. Bipolar I Disorder

A diagnosis of bipolar I disorder requires the presence of only one manic episode, which is not due to the presence of a general medical condition (or any other underlying “organic cause”) or substance use. The manic episode should also be outside the context of a Schizo-Affective or a Schizophrenic disorder.

B. Bipolar II Disorder

Bipolar II disorder is defined by the presence of at least one hypomanic episode and at least one major depressive episode. Patients with a bipolar II diagnosis will primarily suffer with major depressive episodes.

C. Cyclothymia

A milder and more common presentation of Bipolar disorder is defined in cyclothymia. Cyclothymia is diagnosed for people who experience hypomanic symptoms and depressive symptoms without meeting the diagnostic criteria for bipolar episodes for at least two years. Cyclothymia is characterized by changing low-level depression along with periods of hypomania. The symptoms must be present for at least two years in adults or one year in children before a diagnosis can be made. Adults have symptom-free periods that last no longer than two months. Children and teens have symptom-free periods that last only about a month.

D. Rapid-cycling bipolar disorder

This category is a severe form of bipolar disorder. It occurs when a person has at least four episodes of major depression, mania, hypomania, or mixed states within a year. Rapid cycling affects more women than men.

E. Bipolar NOS: A Classification for Sub-threshold Symptoms

The Bipolar Disorder Not Otherwise Specified category includes disorders with bipolar features that do not meet criteria for any specific Bipolar Disorder. Examples include

TREATMENT

Currently there is no definitive cure for Bipolar Disorders. Most of the treatments rely on symptomatic treatment of the disorder using the combination of medicines and therapy. Usually long-term pharmacotherapy is recommended due to high rates of relapse in patients even when using medicines. Most popular and common medicine has been Lithium and sodium Valproate. Lithium is used to treat depressive disorders and acute maniac episodes, while sodium valproate is an anti-convulsion medication. Other anti-convulsion medications include lamotrigine, and carbamazepine which are used for the treatment of acute mania, along with antipsychotic medications such as quetiapine, chlorpromazine and olanzapine for treating and/or maintenance treatment. Anti-depressant medications are used for the treatment of bipolar depression in combination with mood stabilizers in order to avoid switches to hypomania or mania. Older medications also used MAOI (Monoamine Oxidase Inhibitors) but they have fallen out of favor with introduction of new and more effective anti-depressants.

There are some psychotherapy treatments available for maintenance of treatment and reduction of bipolar disorder. These include Cognitive therapy, Behavioral therapy, Cognitive Behavior therapy, Social rhythm therapy, Interpersonal therapy, Family-focused therapy. Despite differences in the treatment targets of each therapy, they all emphasize patient education, mood and routine monitoring and medication compliance.

Behavioral Therapy helps in finding out behaviors that cause stress, anxiety and depression and help in reducing it.

Cognitive Therapy involves of learning to identify and modify the patterns of thoughts that accompany mood shifts in a person. It helps maintain a positive image.

Cognitive Behavior Therapy is a mix of both therapy. It is more effective than doing either one therapy.

Social rhythm therapy helps to develop and maintain a normal and more predictable daily routines. They help in scheduling things to be less stressful and maintain a normal biorhythm of body. For Example, developing a normal sleep cycle, food diet, etc.

Interpersonal therapy involves addressing interpersonal issues by putting emphasis on the way symptoms are related to a person's relationships, including family and peers and aims to reduce strains that the illness may place upon them.

Family-focused therapy (FFT) is also similar to Interpersonal therapy. It is a mix of psychoeducation and family therapy. It helps to improve family communication and supportiveness while decreasing the intensity of negativity. It also teaches patients and their families about the nature of their illness and how to deal with them while being positive about it.

Support Groups also help in dealing with this disorder. These groups specialize in a specific type of disorder so people with same disorder can help and also receive encouragement, coping skills, and related concerns. Patient will feel more accepted and comfortable by being with others in similar situation.

REFERENCES:

1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC

2. Dr Yanni Malliaris - Diagnostic (DSM-IV) Criteria for Bipolar Episodes. Retrieved: http://www.bipolarlab.com/index.php?option=com_content&view=article&id=47:131-diagnostic-dsm-iv-criteria-for-bipolar-episodes&catid=21:bipolar&Itemid=77

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