Mental Health Case Study: Bipolar Disorder 1

Mental Health Case Study: Bipolar Disorder

Brent C. Skall

Youngstown State University

Mental Health Case Study: Bipolar Disorder 2

Abstract

Bipolar Disorder is a mental condition that causes extreme mood swings that include

emotional highs and lows. With depression, a person may feel sad or hopeless and lose

interest or pleasure in most activities. On the contrary, a person with bipolar can also

have their mood shift to mania or hypomania. The manic part of this disease process

causes a person to feel euphoric, full of energy or unusually irritable. To be diagnosed

with bipolar, these mood swings must affect a person’s sleep, energy, activity, judgment,

behavior and the ability to think clearly. Bipolar disorder is a lifelong condition, but

symptoms can be managed with medications and psychological counseling. This case

study will serve to outline a particular patient and their struggle with bipolar disorder. We

will collect data from a clinical setting and gain additional knowledge through the use of

nursing research articles. The purpose of this study is to develop a greater understanding

of bipolar disorder and how it affects the lifestyle of people diagnosed with this mental

illness. This case study will examine one individual in particular; however, the symptoms

displayed by this person tend to apply universally to all those diagnosed with bipolar. It is

important to understand that there are two different types of bipolar disorder: type I and

type II. Bipolar type I is the most severe, with extreme mood swings and the affected

individual losing perception of reality during periods of exacerbations.

Keywords: Bipolar, Disorder, Mental Illness

Mental Health Case Study: Bipolar Disorder 3

Mental Health Case Study: Bipolar Disorder

Objective Data: During the date of care, I examined a 20-year-old male

diagnosed with Bipolar I disorder. To abide by HIPPA regulations, the individual will be

referred to as “TL.” As stated earlier, TL was given the psychiatric diagnosis of bipolar I

disorder. In addition to this diagnosis, TL also suffers from depression, hyperlipidemia,

hypertriglyceridemia, hypothyroidism, and is a marijuana smoker. The patient was

admitted to the unit on March 18th and had previous psychiatric hospitalizations within

the last 30 days. Admission was involuntary and the stated reason was documented in an

ER note. The patient was brought to the ER by police where he produced a hidden bottle

of levothyroxine and stated that he tried to overdose on the medication, and reported

taking as many as 15 pills. During the day of care (March 21st), I was able to make

objective observations by direct communication with the patient. I first gathered

information on the electronic database about the patient, including medications, lab

results, and reason for hospital admission. The lab result I found most useful was the

TSH and T4 levels because they were both related to TL’s diagnosis of hypothyroidism.

Psychiatric medications that TL is on include Bupropion (antidepressant), Citalopram

(antidepressant), haloperidol (antipsychotic), hydroxyzine (anxiolytic), oxcarbazepine

(anticonvulsant), and trazodone (antidepressant). Each drug had a specific use with the

bupropion and citolpram being used to treat depression, the haloperidol and

oxcarbazepine to treat acute psychiatric episodes (mania & depression), the hydroxyzine

to treat anxiety, and the trazodone being used to treat insomnia.

When it came time to interview TL, I was able to make more objective

observations in regards to appearance and behavior. I noticed that TL had an animated

Mental Health Case Study: Bipolar Disorder 4

facial expression, was relaxed, dressed in a neat fashion, and friendly when spoken to.

Affects were pleasurable and seemed normal from what I observed. The patient was also

alert and oriented, and had the ability to come to valid conclusions with awareness to

mental health issues. Although TL was content at the moment and following the

treatment plan, the unit still had him placed on self harm precautions relates to the

suicidal thoughts and ideations. In addition to being prescribed medications to manage

the symptoms, TL also participated in group therapy sessions on the day of care, and

actively communicated with other patients on the unit.

Summarize: Bipolar Disorder presents as episodes of mania and depression. The

classic manic episode is characterized by the discrete appearance of euphoric/elated

mood, talkativeness, decreased need for sleep, impulsivity, hyperactivity, and greater

productivity (Marangoni 2018). With bipolar, circadian rhythms are altered, resulting in

greater fluctuations of energy and activity. When a person has a psychotic episode related

to bipolar, they often experience delusions, hallucinations, catatonic features, and bizarre

behavior. Suicidality is with this disorder as are different forms of aggression, such as

verbal aggression, anger management problems, and violent behavior towards self or

others. Hyper sexuality is also somewhat common in persons suffering from bipolar

disorder, and they tend to have an increased and precocious interest in sexual content as

well as increased sexual behavior.

Bipolar disorder has a lifetime prevalence of 2.1% in adults and 1.8% in children:

at least two-thirds of the patients with bipolar disorder report onset before age 18.

Younger onset is associated with positive family history of mood disorders, comorbidity
Mental Health Case Study: Bipolar Disorder 5

with anxiety and substance abuse disorder, rapid cycling course, treatment resistance,

more hospitalizations, and suicidal behavior (Marangoni 2018).

According to Chris Aiken, MD, the DSM missed two categories of bipolar

disorder that are particularly relevant to developing a treatment plan. They are classic and

atypical bipolar (Aiken 2018). With classic bipolar disorder, hypo/manic and depressive

symptoms are clearly separated, without much overlap. The affected patents displaying

classic bipolar are extremely responsive to lithium therapy. In contrast, patients affected

by atypical bipolar are more responsive to anticonvulsants an atypical antipsychotics.

Atypical bipolar is marked by mixed states, rapid cycling, and a lack of full recovery

between episodes (Aiken 2018). Furthermore, these 2 categories of bipolar disorder can

apply to patients with bipolar I or II, although the atypical form is more common in

bipolar II. In addition to diagnosing these categories of bipolar, it is also of value to look

at other reliable markers of bipolar disorder, such as family history, age on onset, and

treatment response.

Identify: In regards to my patient TL, there were key stressors and behaviors that

precipitated his current hospitalization. As stated earlier, TL was admitted to the

psychiatric unit via pink slip. The reason for the involuntary admission was related to the

patient’s suicidal ideations and attempt at his own life. Police brought TL to the

emergency room, where he produced a hidden bottle of levothyroxine dosed at 75 mcg.

When asked if he had taken any of the medication, the patient stated that he tried to

overdose by taking 15 of the pills. After this, TL was placed on suicidal precautions and

transferred to the psychiatric unit, where I had the opportunity to talk to him about some

precipitating events. As I sat with the patient, I asked him general questions in regards to
Mental Health Case Study: Bipolar Disorder 6

factors leading to the hospitalization. TL stated that, “I was at my nieces birthday party

having a wonderful time one day and the next day I wake up with the idea that I wanted

to kill myself. After this thought came through my head, I called the crisis hotline for

help and the next thing I know, I was taken to the hospital by police because the people at

the crisis hotline had told on me.” The episode of mania described above, followed by

depression is not something that is uncommon for people suffering from bipolar disorder.

When talking to TL, he also seemed tense about losing the job he had just worked so hard

to get and said “what’s the point of living, when I have nothing to live for.” From what

the patient was telling me, he was not compliant with medications, but was accepting of

psychotherapy and medications in the hospital. Levothyroxine is a common treatment

modality for bipolar disorder, so the fact that TL was not taking his medication is reason

to raise concern. In fact, the first blood draw during his hospital stay showed a TSH

reading of 0.23 whereas the target level for his age is right around 1.48. Reviewing

briefly, levothyroxine is used as a treatment for bipolar depression at doses sufficient to

suppress TSH below the lower limit of normal (Phelps 2018). The concern with TL is

that his TSH reading is significantly low and this can exacerbate symptoms caused by

bipolar disorder.

Discuss: When talking to TL about patient and family history of mental illness, he

did state that his mother had bipolar disorder and is now deceased. He denied that anyone

else in his family had any mental disorder. It has been proven that bipolar disorder does

in fact run in families and can be passed down through genetics. TL did state that he had

a great family support system, and that his father and step mom are always there to talk to
Mental Health Case Study: Bipolar Disorder 7

him. The greatest concern made by TL was that he was a burden to his family and that

know one could understand how he felt.

Describe: I observed a lot of evidence based nursing care provided to my

assigned patient TL on the day of care. Treatment of bipolar disorder consists of

medications and therapy and is often a lifelong process. Therapies available include

support groups (sharing experiences among people with a similar condition), cognitive

behavioral therapy (focuses on modifying negative thoughts, behaviors, and emotional

responses), psychoeducation (education that serves to support, validate, and empower

patients), family therapy (helps families resolve conflicts and communicate more

effectively), and psychotherapy (treats mental behaviors through talk therapy). Common

medications used in the treatment of bipolar include anticonvulsants, antipsychotics, and

selective serotonin reuptake inhibitors to name a few. There are also a variety of non-

pharmacological methods available to help alleviate symptoms (i.e. Coloring, music,

television, low-stimuli environments, exercise, yoga, meditation, etc.). While I was on the

unit, TL received medications and also attended a support group, and cognitive

behavioral therapy group lead by a social worker. The cognitive behavioral therapy that

TL attended that day was based on associating words with both positive and negative

feelings and finding ways to modify behavior to produce more feelings of happiness. In

addition to the therapies and medication, TL played chess, colored and listened to music

in his free time.

Analyze: There were some definitive ethnic, spiritual, and cultural influences that

had a major impact on my patient’s life. When it comes to ethnicity, TL falls under the

White/Caucasian category. There were no specific ethnic influences that seemed to have
Mental Health Case Study: Bipolar Disorder 8

a significant impact on his life. Spiritually, TL did not identify with a particular religion,

but did believe in a higher power, which he said helped give his life purpose at times. In

his earlier years, TL attended a Methodist church but stopped going when his mom

passed away. Most of his spiritual beliefs stemmed from what he was taught from his

mother, so he holds them tightly. When it comes to cultural influences, TL stated that he

comes from a culturally diverse background, and associates with his Christian roots. He

regularly spends time with his family during Christian holidays such Christmas and

Easter. TL’s family has also been very supportive and tries there best to help him find

purpose and meaning in life.

Evaluate: The patient is responding well to treatment modalities. TL was

compliant with taking all medications while in the hospital. Additionally, he had attended

every group therapy session during the hospital stay and has been seeing improvement in

overall mood. TL has also begun to develop new coping strategies that are more efficient

than older ones. Moreover, he has spoken to therapist while in the hospital and has been

responding well to therapy sessions. There have been no manic episodes during the visit;

no intentions to harm self or others, and better sleep patterns. TL believes the reason he

has responded so well to the treatment plan is because the hospital has provided him with

a structured schedule that provides time for self-reflection and healing. When interacting

with the patient, I noticed he had pleasurable affects, was oriented and had no

disturbances in thought process or perceptual disturbances. TL had good judgment,

meaning he was able to form valid conclusions and behave in a socially appropriate

manner. Overall, the treatment plan seemed appropriate for the patient.
Mental Health Case Study: Bipolar Disorder 9

Summarize: The care team has developed specific plans for TL following

discharge. From the information I gathered, TL plans to continue to attends support

groups and have individual therapy sessions with his psychiatrist. In regards to

medications, they plan on keeping a close eye on his compliance and only giving a week

supply at a tome. Once the supply runs out, TL is to schedule a visit with his doctor to get

refills and determine if the medication is effective and serving its correct purpose. He will

also get blood draws to check TSH and T4 levels, as hypothyroidism is closely associated

with bipolar disorder and the disease process. Patient is to report any adverse side effects

to the primary doctor immediately and to not discontinue medication without first talking

to a doctor. TL also expressed that he has a readily available support system in his family,

and can openly discuss any problems that he is having. Use of distraction techniques,

such as playing board games, video games, and hanging with family and friends will

continue to help TL with his mood. After discharged from the hospital, he also plans on

returning to his job and saving enough money to buy a house.

Prioritized list of NANDA diagnoses:

• Disturbed sleep pattern r/t episodes of delusion as evidence by hallucinations and

inability to sleep

• Self care deficit: dressing and grooming r/t depression as evidence by physical

appearance

• Disturbed thought process r/t mood alteration as evidence episodes of delusions and

hallucinations

• Risk for suicide r/t mood alteration secondary to bipolar disorder as evidence by

verbalization of suicidal ideations and suicide attempt (drug overdose)

Mental Health Case Study: Bipolar Disorder 10

List of potential nursing diagnoses:

• Chronic low self-esteem r/t anxiety

• Hopelessness r/t feeling of abandonment

• Defensive coping r/t to anxiety

• Risk for directed violence r/t bipolar disorder

• Interrupted family process r/ deterioration of family functioning

Conclusion: In summary, we have discussed bipolar disorder and the impact it

had on my patient. The importance of understanding bipolar disorder and the thought

process behind is key. Knowing the signs and symptoms of the mental illness helps

caregivers to develop a treatment plan that is individualized to the patient. Although

bipolar cannot be cured, we can help treat symptoms and help those suffering with the

illness to lead a happy and productive life. The aim of this study was to inform readers on

bipolar disorder and to discuss the affect it has on a specific person. Through the

collection of both objective and subjective data, we are able to form conclusions about

the mental illness and have a better understanding. There were a variety of different

factors that played a role in this case study, such as patient stressors, patient and family

history of the illness, ethnic, spiritual, and cultural influences, and plans for discharge.

We must take each of these factors into consideration when developing a care plan if it is

to be successful. The aim with most mental disorders is to treat the symptoms, not to cure

them. Being mindful and understanding helps to ensure that those suffering from bipolar

receive the best care possible.

Mental Health Case Study: Bipolar Disorder 11

References

Marangoni, C. (2018, October). ADHD, Bipolar Disorder, or Borderline Personality

Disorder: Getting to the Right Diagnosis. Psychiatric Times, 35(10), 18+.
Retrieved from
http://link.galegroup.com/apps/doc/A574175700/PPNU?u=ohlink104&sid=PPNU
&xid=3de239bc

Phelps, J. (2018, October). A New Treatment for Bipolar Depression. Psychiatric

Times, 35(10), 14. Retrieved from
http://link.galegroup.com/apps/doc/A574175687/PPNU?u=ohlink104&sid=PPNU
&xid=4600cbb3

Aiken, C. (2018, May). Two Categories of Bipolar Disorder That Can Change
Treatment. Psychiatric Times, 35(5), 20A+. Retrieved from
http://link.galegroup.com/apps/doc/A574177392/PPNU?u=ohlink104&sid=PPNU
&xid=e5bfb4be