Case Study Outline

Diagnosis

Axis I: Bipolar Disorder I, Most Recent Episode Depressed

Alcohol Abuse (Provisional)

Axis II: None

Axis III: None reported

Axis IV: Problems related to the social environment, occupational stress,

Axis V: GAF = 65

Signs/Symptoms of each disorder listed on the 5 Axes:

Margaret was given a primary diagnosis of Bipolar Disorder I, most recent episode depressed. When reviewing the case it was clear that she met the criteria for major depressive episode and manic episode. Specifically, it was noted that Margaret experienced the following depressive symptoms over a period of about two weeks: depressed mood throughout the week, loss of interest in activities, insomnia, fatigue, feelings of worthless and diminished ability to think. It is evident that Margaret has six of the symptoms noted in the DSM-IV for major depressive episode. In addition, Margaret’s symptoms do not meet the criteria for a mixed episode. The symptoms have caused distress in both her occupational and social areas. The symptoms do not appear to be due to the direct physiological effects of a substance or general medical conditions. In addition, her symptoms are not accounted by Bereavement. Thus, it is evident that she meets the criteria for major depressive episode.

In regards to manic episode, the case notes detail that Margaret has experienced different bouts of “highs” which have lasted at least one week. During these “highs” Margaret only sleeps 4-5 hours a night, is more talkative than usual and tends to be distractible. The symptoms do not meet the criteria for mixed episodes. Margaret continues to experience problems in her occupational and social pursuits. Finally, the symptoms do not appear to be related to the physiological effects of a substance or general medication condition.

Given that Margaret meets the criteria for both a major depressive episode and manic episode Bipolar Disorder I seem to fit her current symptomatology. She currently is experiencing a depressive episode, and has experienced manic episodes in the past. The mood episodes that are detailed are not better accounted for by Schizoaffective Disorders and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder NOS.

A provisional diagnosis of alcohol abuse was also given. The case notes states that Margaret abused alcohol in the past. Additional information will need to be collected in order to determine if this diagnosis is warranted and to gather information about any current use or abuse.

Margaret does not appear to have an enduring pattern of inner experience or behaviors that deviates markedly from the expectations of her culture and therefore she does not have a personality disorder diagnosis on Axis II. It appears that she does not have any problems in her intellectual abilities.

There were no health concerns reported in the case notes. Additional information will be gathered after assessment to rule out any medical concerns that may be contributing to Margaret’s stress level.

On Axis IV Margaret’s psychosocial stressors were occupational and social stress. Her co-workers are noticing her changes in moods and it is reported that she is continuously overworked. In addition, social problems began to occur as a result of her relationship with another sister in her congregation.

Margaret was given a GAF score of 65. She is currently depressed and is experiencing some/moderate difficulty in occupational and social functioning.

Differential Diagnoses:

A differential diagnosis of ADHD should be considered for Margaret. It was reported that Margaret was experiencing difficulties with focus and controlling her thought processes. The case data also notes that she is distractible. In addition, the case notes state that Margaret talks excessively at times and at times is “on the go.” These symptoms suggest a possible diagnosis of ADHD. In the data that was retrieved, there is not enough evidence to diagnosis Margaret with this additional condition. Additional testing and information should be gathered to determine if Margaret meets those criteria for ADHD.

In reviewing Margaret’s case it was imperative to determine whether she was experiencing symptoms of major depressive disorder or bipolar disorder. Margaret fully met the criteria for major depressive episode and manic episode, which clearly pointed to a diagnosis of bipolar disorder. It was important to then determine whether her periods of “highs” were that of a hypomanic, manic or mixed episode. She met the criteria for manic episode, which narrowed down the diagnosis to Bipolar I disorder.

TREATMENT PLAN

Name:Margaret

Problem List:

- Depressed Mood- sleep difficulties, feelings of worthless, sad, fatigue, no pleasure in activities

-Manic episodes- distractibility, seems on the go, problems thinking, talkative,

- Social Problems- others on edge around her, involved with another co-worker

-Occupational problems- co-workers reporting changes, stressed due to work demands

- Previous problems with alcohol

Patient’s Strengths:

- Energetic

- enjoys her employment

-desires change

Factors that Impede Treatment:

- High work demand

- Limited time for therapy

OVERALL GOALS FOR TREATMENT / MEASURABLE OBJECTIVES TOWARDS EACH GOAL
1. Decrease depression /
  1. Engage in one rewarding activity/day
  2. Reduce negative automatic thoughts
  3. Sleeping 7-8 hours a night
  4. Increase social contacts
  5. Increase self-reward for positive behaviors
  6. Modifying schemas of worthlessness
  7. Eliminating all depressive symptoms (BDI<10 for 1 month)
  8. Acquire relapse prevention skills

2. Reduce anxiety/stress level /
  1. Receive psychoeducation about Bipolar disorder
  2. Reduce physical symptoms of anxiety
  3. Reduce negative automatic thoughts
  4. Learn breathing techniques
  5. Learn progressive muscle relaxation techniques
  6. Acquire relapse prevention skills

Patient’s Signature______Date:______

Therapist’s Signature: ______Date:______