WYANT CASE STUDY 1

Bipolar 2 Disorder Case Study

Emily Wyant

September, 23, 2017

Youngstown State University

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Abstract:

Bipolar II is a disorder that effects mood greatly. A person affected can suffer from

periods of depression and hypomania. A patient with mast cell disease also can affect bipolar

disorder. With an increase in histamine, many different things can happen to the body. A two

week assessment and analysis of a patient with both of these issues is discussed. Symptoms of

bipolar disorder and nursing diagnoses are presented in this paper.

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Objective Data:

The patient, JB, was admitted on September 5, 2017. Her husband brought her to the

emergency department because she was acting bizarre from not taking any of her medical or

behavioral medications. He was concerned that she was not able to take care of herself, making

the patient an involuntary admission. I had first met the patient on September 7, 2017, but then

had the same patient the week after on the 14 of the month. The first week that I cared for JB,

the diagnosis was schizophrenia, but the doctors had misdiagnosed this patient. More

assessments were performed and the diagnosis of bipolar 2 disorder in a manic episode was

decided on. According to the DSM IV-TR,

“Bipolar II disorder is characterized by a clinical course of recurring mood episodes

consisting of one or more major depressive episodes and at least one hypomanic episode.

The major depressive episode must last at least two weeks, and the hypomanic episode

must last at least four days, to meet the diagnostic criteria. ” (American Psychiatric

Association 2013).

Upon admission, JB barely said anything to any of the staff. Any information was obtained from

the husband. The patient was having delusions and conversations jumped from topic to topic if

she did say anything. The patient was screaming on the unit and was in obvious distress. The

first day of care for the patient I had to pace the hallway with her to talk to her at all. She was

very restless and had the extreme urge to move around. She complained of severe pain in her leg

and said she could not sit down. Her facial expressions were very animated and she was moving

her mouth and tongue a lot while making several different noises. The patient had a blanket and

covered her head and face with it several times while I was trying to have a conversation with

her. Any sentences spoken were short and some didn’t make any sense. JB had a flight of ideas
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throughout the day and would often go back and repeat the same words that she had already

stated. Her thoughts were poorly organized and auditory and visual hallucinations were present.

She would look to the side and say things to the air, and she mentioned that the one room was an

ocean and she saw waves. The next week, there was a huge improvement in the patient’s status.

JB was able to hold down a normal conversation and answer any questions that I had for her.

The hallucinations and delusions had disappeared with treatment and the patient was relaxed and

enjoyable to talk to. She sat us at a table in the common area away from the other tables because

she is deaf in one ear and hard of hearing in the other. JB stated that this occurred as a result of

her mast cell disease. The patient has many allergies, fibromyalgia, Raynaud disease, a lumbar

herniated disc, and lupus. Most of the medical treatment for the patient is centered on

controlling her mast cell disease. The patient stated that it affects every organ in her body and

even the way she thinks. Safety measures were attained on the unit by locking the door to not let

the patient escape or get out, and making sure that the patient is calm and not combative. The

patient was prescribed medications for her psychiatric condition. The patient was taking 30mg

of duloxetine daily for anxiety and depression, and 5mg of olanzapine twice a day for her bipolar

disorder.

Summary:

‘Bipolar II disorder is not characterized by manic episodes but by depressive episodes as

well as hypomanic episodes that occur in cycles” (Bipolar II 2017). This type is more common

than bipolar I disorder, and the unpredictable severe changes in mood cause problems to function

in day to day life. In between episodes the patient is normally able to participate in the usual

activities of daily living. “However, these patients have a more chronic course, significantly

more depressive episodes, and shorter periods of being well between episodes than patients with
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bipolar disorder I” (Simon 2013). Because of the exaggerated periods of depressive episodes, a

person suffering from this disorder is at a higher risk of suicidal behaviors and tendencies. The

cause is unknown but many factors are believed to play a role in developing bipolar disorder.

These include: environmental, genetic, and biochemical factors. It is often passed down through

families and affects the neurotransmitters, dopamine, serotonin, norepinephrine, in the brain.

This disorder can affect a person of any gender or any age, but normally it is first diagnosed

between the ages of 15-30.

Common behaviors that are associated with bipolar disorder are those that fall under

depression or hypomanic episodes. A person experiencing a depressive state may feel hopeless

and have a disinterest in the things that they used to want to do. Physical symptoms include

fatigued and restlessness. The person may be unfocused or indecisive. If the patient is

experiencing an episode of hypomania, they feel very happy. “Many patients feel that there is

nothing wrong during these periods, but family members may notice the change from their loved

one’s usual behavior” (Bipolar II 2017). It is crucial for the patient to get treatment during these

times because it can progress to a manic episode. One of the most common causes of bipolar

disorder is undermethylation. “This condition is innate and is characterized by low levels of

serotonin, dopamine, and norepinephrine, high whole blood histamine and elevated absolute

basophils” (Walsh, n.d.). JB’s histamine levels in her body are increased because she is

diagnosed with mast cell disease.

JB’s mast cell disease is something that can affect her behaviors. This is “where the body

produces too many mast cells, [and] where even [a] normal number of mast cells are too easily

activated by a trigger to release their contents, called mediators” (About Mast Cells 2017). With

this disease, there is an increase in histamine in the body because the mast cells release it. This is
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a reason why the patient has so many allergies and has had many instances where she was in

anaphylactic shock. JB has a very aggressive form of this disease and has even received

chemotherapy as a form of treatment. Mast cell activation can cause a variety of psychiatric

symptoms to arise. “Brain fog, including short term memory troubles and word finding

problems, is the most common symptom. Irritability, anger, depression, bipolar affective

disorder, ADD, anxiety, panic disorders and even sometimes frank psychosis can present. Such

symptoms in mastocytosis patients were referred to as mixed organic brain syndrome” (Klimas

2014). The increase in histamine causes several reactions and symptoms to occur in the body.

Patients experience skin rashes, nausea, headaches, and bone pain. Heat, cold, and stress are

triggers for the disease to have exacerbations.

Identify:

JB was in the hospital for her mast cell disease for 12 days prior to being admitted to the

behavioral unit. She stated that she was in for an exacerbation of the disease. It was triggered

from working long days in the heat on the horse farm that she owns. From being in the hospital

JB was exhausted. She said that she got periods of thirty minute naps during her entire stay in

the hospital. My patient stated that she basically didn’t get any sleep for the entire twelve days.

From this exacerbation of the mast cell disease, an increased histamine occurred is JB’s body and

her bipolar disorder was developed. She experienced a period of mania in the behavioral health

unit.

Discuss:

There is no family history of bipolar II disorder in the patient’s family. However,

“according to a study published in the American Journal of Psychiatry, 40 percent of participants

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with first-degree relatives diagnosed with bipolar II and 22 percent of those with first-degree

relatives diagnosed with bipolar I disorder were diagnosed with bipolar II” (Bipolar II 2017). On

the other hand, there is a familial tendency present for mast cell disease. The patient stated that

her mother has the disease as well as both of the patient’s children. As mentioned previously,

this medical condition can be correlated to the development of bipolar disorders.

Describe:

The psychiatric nursing care provided to the patient is very diverse. The nurses made

sure to give the patient her medication daily to help control some of the symptoms she was

experiencing. Each day the nurses asked the JB to choose a goal for the day to try to make

herself feel a sense of accomplishment and autonomy. The first time I met my patient her goal

was to take her medication and drink more water. The next week her goal was to center herself

to make sure she was ready for discharge and for the court date that she had to go to. Every day

each patient had the option to go to group therapy. The first day of care for JB, she was not

attending group meetings. The next time I saw her, she told me that she was doing everything

that was wanted of her to try to go home. This included going to group sessions and talking

honestly with all the nurses and doctors.

Analyze:

JB stated that she was a melting pot of ethnicities. She grew up in California and became

a certified dog trainer there. This is important to her because she has a service dog for her mast

cell disease and she was able to train her dog, Blue. Her son also has a service dog that she was

able to train to provide him with the right dog that was needed. Later in life she worked on a

cattle ranch in Idaho and fell in love with farm life. This led to her wanting a farm as an adult
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and succeeding in that dream. The patient stated that she is a spiritual person. She said that she

hasn’t been to church in a while because she has a problem with organized religion. She doesn’t

think it is okay to go to church and act one way on Sunday and then become a different person

and not follow the way of God on Monday. JB stated that she is Christian but she was raised

Presbyterian. She believes in living life to follow God and that He can help everyone through

anything.

Evaluate:

When the patient was first admitted onto the unit the nurses had several outcomes that

required participation and cooperation of the patient. Outcomes were that the patient could hold a

directed conversation without jumping from topic to topic. The patient would take her

medications and drink water with them. The patient had many allergies and did not trust the

food, so an outcome for the patient to eat on the unit. The nurses had a goal for the patient to

shower and to interact with others on the unit. As JB’s status improved, the outcomes related to

care prepared the patient for discharge.

Summarize:

The patient stated that her plans for discharge are to return home to her husband and two

children. She wants to return to working on the farm with her adoptive father. She stated that

she and her dad are turning the farm into a business and a lot needs done to get the ball rolling.

She plans to continue with the business when she gets home and hopefully ends up being able to

work the farm from inside her house. She wants to spend time with her children and help raise

them to enjoy want they want to in life and not to be peer pressured into doing something they
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don’t want to. She said that her daughter is bullied for being a farm girl and she wants to teach

her that she can be whatever she wants to be.

From a nursing standpoint, I want the patient to continue taking her medication for her

mast cell disease and bipolar disorder at home. I want the patient to wear sunscreen when it is

hot outside and try to stay in the shade and avoid direct sunlight. I want her to dress warm in the

winter and avoid excess stress. These are the triggers of her mast cell disease that she can try to

minimize or avoid. The patient should see a counselor to learn coping skills for her bipolar

disorder and learn more about it since she was just recently diagnosed with it. Also the patient

should see a medical doctor to make sure the treatment for her mast cell disease is still under

control and working.

Prioritized:

For the first visit:

1. Acute Confusion related to delirium, fluctuation in sleep-wake cycle as evidenced by:

hallucinations, increased restlessness, fluctuation in cognition.

2. Anxiety related to health status, stress as evidenced by: diminished productivity,

extraneous movements, glancing about, poor eye contact, restlessness, apprehensive,

focus on self, irritability, jittery, confusion, difficulty concentrating, impaired attention.

3. Impaired verbal communication related to altered perceptions, psychological barriers,

stress as evidenced by: absence of eye contact, difficulty forming sentences, difficulty in

maintaining usual communication pattern, inappropriate verbalization.

The second time I cared for the patient:

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1. Interrupted family processes related to shift in health status of a family member as

evidenced by: communication pattern changes, changes in availability for

affective responsiveness.

2. Readiness for enhanced communication as evidenced by: expresses satisfaction

with ability to share ideas with others, expresses thoughts, and expresses

willingness to enhance communication.

List:

1. Risk for spiritual distress as evidenced by mental illness.

2. Risk for caregiver role strain as evidenced by unpredictability of condition.

3. Risk for powerlessness as evidenced by inability to control changes in mood.

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References:

American Psychiatric Association (2013). Bipolar and Related Disorders. DSM Library. .

Retrieved from:

http://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425596.dsm03

Klimas, L. (2014). MCAS: Neurologic and psychiatric symptoms. Mast Attack. Retrieved from:

http://www.mastattack.org/2014/10/mcas-neurologic-psychiatric-symptoms/

Simon, H. (2013). Bipolar Disorder. University of Maryland Medical Center. Retrieved from:

http://www.umm.edu/health/medical/reports/articles/bipolar-disorder

Walsh, W. (n.d.). Three Most Common Causes of Bipolar Disorder. Walsh Research Institute.

Retrieved from: https://www.alternativementalhealth.com/three-most-common-causes-of-

bipolar-disorder/

(2017). About Mast Cells. MastCellAware. Retrieved from:

http://www.mastcellaware.com/mast-cells/about-mast-cells.html

(2017). Bipolar II. Dual Diagnosis. Retrieved from: http://www.dualdiagnosis.org/bipolar-

disorder-and-addiction/bipolar-ii/