The case of George provides a perfect background for the exploration of conditions leading to the development of bipolar I disorder. The patient shows various symptoms that have been included in the diagnostic criteria for bipolar I disorder. These symptoms have interfered with the patient’s functioning in social and professional environments, and have escalated over time without effective management. The patient needs to be treated to enhance his self-care effectiveness.
Case Details
Description
A 34-year-old male patient is brought for care by his brother. He has a height of 1.62 m and weighs 68 kg. He presently does not smoke although he had been smoking both cigarettes and marijuana since his teenage years and only stopped about 2 years before the episode. He is currently under no prescribed medication and is not a frequent seeker of medical services. His medical history indicates that he does not suffer from any chronic conditions and has not shown any symptoms worth worrying about. His last full body examination also showed no symptoms of any illness. Upon physical observation, George does not exhibit any symptom of physical illness and needs to be psychosocially examined to develop an effective diagnosis.
The concerns reported by the patient indicate the possibility of bipolar disorder. The patient reports experiencing episodes of extreme irritability and moodiness. The episodes are often preceded by periods of depression, during which he does not feel like doing anything. At times, such episodes are characterized by mixed features; he may, for instance, feel extremely tired, melancholic, rapid cycling, and seasonal patterns of symptom appearance. The disturbances experienced during such times prevent George from attaining effective occupational functioning; at times, this has been a cause of severe impairment to his social functioning. These symptoms have been recurring over the last six months and are increasingly getting stronger. More recently, they have been lasting more than one week at a time and occur through a major part of every day. During other periods, he feels the pressure to be more talkative than usual, feels less need to sleep, and can feel rested even after as little as 2 hours of sleep. He is also easily distracted during such periods, and can exhibit increased focus on goal-oriented activities, particularly with the strong desire to control his business (he describes his business as a life-achievement), or non-goal-oriented activities aimed at attaining psychomotor agitation such as the destruction of personal property. He gets frequently involved in activities with high probability of harm such as sexual recklessness as he feels extremely energetic during such periods.
From the description of the symptoms exhibited by the patient, he has been diagnosed to be suffering from bipolar I disorder. DSM V characterization of bipolar I disorder indicates that a patient must be suffering from manic episodes lasting for one week at a time and for most of the day, in alternation with periods in which different abnormal behaviors such as increased wakefulness are exhibited (McIntyre, 2019). The range of symptoms provided as part of the DSM V criteria for bipolar I disorder include; reduced need for sleep, feelings of grandiosity, distractibility, increased feelings of high self-esteem, and increased activity (Bobo, 2017). Patients have to exhibit at least four of these symptoms to be diagnosed with bipolar I disorder, as clarified by DSM V (Bobo, 2017). Since George exhibits a combination of several of these symptoms, he has been diagnosed to suffer from bipolar I disorder.
Etiology
The main cause of bipolar I disorder remains unknown. However, various possible factors have been linked to the disorder including a combination of developmental, environmental, and genetic factors (Rowland & Marwaha, 2018). Reviewing the patient’s family history, it is possible that a combination of genetic disorders and environmental factors contributed to George’s condition. George reported that his father had exhibited some of these symptoms and had been advised to see a therapist before he passed on. It is, therefore, possible that George has a genetic predisposition for bipolar I disorder. According to Rowland and Marwaha (2018), individuals with first degree family members diagnosed with bipolar I disorder are 5-10% times more likely to develop bipolar disorder compared to the general population.
Other factors that may have contributed to George’s condition include anxiety about seasonal unemployment and low income levels. As a repairman, George frequently faced seasonal periods of unemployment in the past, which caused him a lot of anxiety and led him to start his own company one year before the time of presentation. Since the company started, he has not attained profitability and seasonally faces low income levels, an outcome that has resulted in significant stress. Other factors that are assumed to have played significant roles in the George’s condition include marijuana use and possible emotional abuse during childhood, as he reports that he had not been close to his parents and they often used demeaning words against him in a bid to deter him from wrongdoing. Rowland and Marwaha (2018) confirmed that both marijuana use and emotional abuse during childhood are possible risk factors for bipolar I disorder. It is, therefore, possible that George is experiencing the effects of his prolonged use of marijuana, and he may also be unconsciously dealing with the desire for approval due to emotional abuse during his childhood.
Functioning
The condition has had negative impacts on George’s social functioning across various spheres. At the family level, George had been a loving husband to his wife and a great father to his children. However, the instances of irritability, depression, and moodiness have resulted in strained relationships between himself and his family members. The increasing intensity and durations over which he exhibits irritability and moodiness have also resulted in escalated tension in his family. His children no longer have fun staying around him and mostly avoid his presence as they do not know what to expect from him. Presently, the only person who seems to understand George is his younger brother who is a doctor. George’s brother has been encouraging him to seek medical help, hence the visit.
Previously, George had good social relations with his workers as well as several friends with whom he would play football over the weekends. He really enjoyed football, but this has become a dream due to his manic experiences. He longs to be better again so that he can reconnect with his friends and continue playing football. He has also stopped going to church, which he would not miss previously on any Sunday and during religious functions, as he feels conscious of his condition and fears that he is being watched by everyone in the congregation. However, he still attends to his business; he has informed the employees of his health issues and advised them to call his brother in case he needs help at any given time. George tries to prevent distractions at his work as he feels that he would not be able to take care of his family without the business. It is, however, becoming difficult for him to sustain the operations due to the escalated intensity and duration of the manic episodes associated with his condition.
George’s self-care capabilities have also been affected by the condition. He previously enjoyed morning exercise routines and would visit the gym thrice every week. He also had his haircuts every week at a neighborhood barbershop. These routines have since changed as he fears going into public places due to the unpredictable appearance of his symptoms. He would visit his brothers in their family home where they frequently had barbeques. These trends have gradually declined over the past one year due to the increasing frequency of manic episodes. George wishes he can be helped to treat his condition so that he can resume his normal activity.
Treatment
George’s treatment will be carried out with the goal of managing the symptoms of bipolar I disorder. The desire is for George to resume his normal functioning and to improve his quality of life. The selected treatment of choice will be a combination of pharmacological and psychological treatments. Bipolar I disorder is a lifelong condition that requires continuous treatment even during the periods when the patient feels well. The treatment plan will include a psychiatric nurse, a psychologist, and a social worker if necessary. This combined treatment has been reported to be effective in managing the symptoms of bipolar I disorder due to its multicomponent characteristic and is frequently used with success (McCormick, Murray, & McNew, 2015). The choice of medications and psychological support processes will be outlined in the treatment plan.
Based on the diagnosis, the objective of pharmacotherapy in George’s case will be for maintenance treatment with the goals of preventing the recurrence of the manic episodes. A combination of different medications will be used as recommended by McCormick et al. (2015). These include mood stabilizers and atypical antipsychotics. The mood stabilizer of choice in George’s case is lithium. Quetiapine will be used as the atypical antipsychotic as it has been proven to be the only effective antipsychotic monotherapy for maintenance treatment of manic episodes of bipolar I disorder (McCormick et al., 2015). Since George has exhibited rapid cycling, the combination of mood stabilizers and atypical antipsychotics will be sufficient as the pharmacotherapy of choice. No antidepressants should be used by the patient as it may result in a switch to mania due to the rapid cycling (McIntyre, 2019). This will be included in his medical records to avoid future pharmacological mishaps. The patient is expected to use these medications continuously due to the life-long nature of bipolar I disorder.
George will also be subjected to psychosocial treatments such as counseling to help him understand the condition, the need for its management and attain effectiveness in self-care. Psychosocial treatment has been found effective for patients with bipolar I disorder due to its long-term benefits such as reduced duration of hospitalization and frequency of symptoms (Bobo, 2017). Cognitive behavioral therapy has been specifically recommended for George. As part of the cognitive behavioral therapy, George will be encouraged to seek peer support such as through interactions with family members, support from the workplace, and social group education on the disease and its outcomes. Cognitive-behavioral therapy among patients with bipolar I disorder helps in improving compliance with medications, enhancing the ability to recognize the triggers to the manic episodes, and in development of early intervention strategies aligned to the condition (McCormick et al., 2015). The combination of pharmacological therapy with cognitive behavioral therapy helps to prevent relapse. It can be concluded therefore, that the choice of therapy approaches will be effective towards ensuring successful treatment for George.
The advantages of using the combined pharmacological and psychosocial treatment for the patient include its effectiveness in addressing some of the common challenges in the management of bipolar I disorder. The most common challenge is non-adherence to medication, which is expected to be addressed through cognitive behavior therapy. Some of the reasons that have been mentioned for non-adherence to medications among patients with bipolar I disorder include the lack of belief in the effectiveness of pharmacotherapy and denial of the diagnosis (Bobo, 2017). Through cognitive behavior therapy, these issues will be addressed, hence changing George’s attitudes towards pharmacological treatment.
Conclusion
George was diagnosed based on the DSM V criteria for bipolar I disorder. The patient showed various symptoms including manic episodes lasting for more than one week at a time and for several hours daily. From a review of the patient’s family history, it has been seen that the probable risk factors that may have contributed to George’s condition include the genetics, environmental factors such as low income and unemployment, marijuana use, and emotional abuse during childhood. George does not use any harmful substances and is not suffering from any chronic conditions. The treatment would, therefore, target only reduction of the patient symptoms and will include pharmacotherapy and psychosocial treatments. Both have proven effective for the treatment of bipolar I disorder.
References
Bobo, W. V. (2017). The diagnosis and management of bipolar I and II disorders: Clinical practice update. Mayo Clinic Proceedings, 92(10), 1532-1551. https://www.mayoclinicproceedings.org/article/S0025-6196(17)30544-X/fulltext
McCormick, U., Murray, B., & McNew, B. (2015). Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses. Journal of the American Association of Nurse Practitioners, 27(9), 530-542.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5034840/
McIntyre, R. S. (2019). Pharmacological treatment of bipolar disorder: 2017-2018 update summary. Medicaid Mental Health, 21-23. https://medicaidmentalhealth.fmhi.usf.edu/_assets/file/Guidelines/2017-2018%20Treatment%20of%20Adult%20Bipolar%20Disorder.pdf
Rowland, T. A., & Marwaha, S. (2018). Epidemiology and risk factors for bipolar disorder. Therapeutic Advances in Psychopharmacology, 8(9),-