Bipolar Disorder Treatment Plan

BIPOLAR DISORDER TREATMENT PLAN

Lukisha Harmon

Western Carolina University

RTH 352- Recreational Therapy Process and Techniques

Jennifer Hinton

April 29, 2016

Case Study

Abstract:

This resident is a 15-year-old male diagnosed with multiple behavioral and mental illnesses that include bipolar disorder, oppositional defiant disorder, attention deficit hyperactivity disorder (ADHD), and substance abuse. Patient was referred to this inpatient psychiatric facility by a local hospital and Office of Children’s Services. He was transferred to this unit on 07/10/2015.

Key Words:

Oppositional defiant disorder, ADHD, bipolar, polysubstance dependence, cognitive disorder

Purpose Statement:

The purpose of this case study is to understand the diagnoses and course of treatment of this 15-year-old male and to examine the use of team sports, yoga, guided meditation, and teambuilding as RT interventions to address patient and treatment team objectives.

Chief Complaint:

The resident was referred for a history of high risk behaviors, depression, elopement risk, and suicidal ideation.

History of Present Illness:

This is a 15-year-old Native American from the northwest. He is in OCS custody. Apparently, there is a history of parental substance abuse and neglect. The resident has been residing with his grandmother since 04/01/2015, when he returned from residential treatment at a facility in another state on 08/21/2014 and was allowed to live with his father; however, his father resumed drinking and the resident was moved to his gradnmother’s house on 04/01/2015. She reports that his behavior has been esculating since then. He himself started drinking several times a week, often to the point of blacking out and also smoking marjijuana. When he saw his outspatient provider, he expressed some suicidal ideation and became very agitated and was referred to the regional hospital. The patient reports that he is not currently suicidal. He reports no auditory or visual hallucinations and reports no delusions. The resident carries a diagnoses of bipolar disorder, NOS. He does not currently exhibit any manic behaviors and does not report any history of manic behaviors, however, it does not appear that in the past, he had a history of extreme tantruming, aggression, and disruptive behaviors.

Past Psychiatric History:

The resident has a history of two inpatient admissions at this inpatient psychiatric hospital. He was first admitted on 09/30/2013. He was discharged at the end of Novemeber 2013 and sent to another facility for care. He was discharged on August 21, 2014 and followed up with an outpatient behavioral health clinic. He was at a Boys and Girls Home from 03/22/2013 to 09/20/2013. He was transferred at that time to this facility for aggression. The resident was most recently admitted to this facility on 04/29/2015. The resident carries diagnoses of ADHD; ODD; bipolar disorder, NOS; cognitive disorder, NOS; history of polysubstance abuse; and rule out FASD. Currently, the resident is on Abilify 15 mg daily at 2 p.m. In the past he has been on Concerta 64 mg daily in the morning. He has also been on Prozac 10 mg twice daily and Seroquel 200 mg daily in the morning and 300 mg daily at 5 p.m. Apparently, he was taken off all the medication by his father when he returned from the residential facility. The resident has no history of suicide attempts.

Family History:

His bioligical father and mother both have a history of alcohol dependence. No history of suicide in the family is reported.

Medical History:

The resident reports no medical problems. No history of loss of consciousness or TBI’s.

Developmental History:

Exposure to alcohol in utero is suspected, but not documented. No history of perinatal trauma or developmental delay. No history of enuresis or encopresis.

Substance Use History:

Please see HPI.

Social History:

The resident is currently in 9th grade. He reports that he is in normal classes, but receives mostly D’s. He has a history of suspensions due to his behaviors, but no history of legal problems. Until 2013, he lives with his biological parents, at which time OCS took custody. After sometime in residential and acute inpatient treatment, he was returned to his father’s custody, but then removed again in the Spring of 2015 because his father was abusing alcohol.

Review of Symptoms:

The resident denies general, GI, GU, cardiovascular, respiratory, or neurologic complaints.

Vital Signs:

Blood pressure 132/77, pulse 69, and temperature 97.9.

Allergies:

No Known Drug Allergies (NKDA)

Mental Status Exam:

General Apperance: This is a 15-year-old male who appears his stated age. Neatly dressed and groomed. Cooperative with the interview. Eye contact is fair.
Speech: Impoverished
Psychomotor Activity: Within normal limts.
Affect/Mood: Mood reported as okay. Affect is restricted.
Thought Process: Concrete
Thought Content: Reality-based. Denies auditory and visual hallucinations. Currently denies thoughts or suicide, self-harm, or harm to others.
Orientation: He was oriented to person, place, time, and situation.
Memory: Able to answer 4/4 general knowledge questions. Able to remember 3/3 words after 5 minutes. Was able to do serial 3’s but not serial 7’s. When asked what he will do if he found somebody’s wallet in the store, he reports that he would take the money. When asked if he has three wishes, the resident states that he would like to go home and has no other wishes. He reports that he doesn not know what he wants to be when he grows up.
Estimation of Intelligence: Below average.
Judgment and Insight: Assessed to be poor.

Assessment:

This resident requires residential treatment for ongoing treatment of high risk behaviors and depression.

Assets:

This is a 15-year-old male who enjoys good health. He likes basketball and has a positive attitude towards treatment.

Liabilities:

Include a family history of substance abuse, personal history of substance abuse, possible exposure to alcohol in utero, cognitive impairment, history or poor judgment, and a history of witnessing domestic violence and neglect. He also has a history of suicidal ideation.

Provisional Diagnoses:

Axis I:Attention deficit hyperactivity disorder

Oppositional defiant disorder

Bipolar disorder, not otherwise specified

Cognitive disorder, not otherwise specified

History of polysubstance dependence

Axis II:No diagnosis
Axis III: Rule out fetal alcohol spectrum disorder

Psychiatric/Medical Psychosocial Stressors

Axis IV: Severe
Axis V: GAF- 40

Initial Treatment Plan of Care:

The resident has been admitted to residential treatment. History and physical be provided. The clinical therapist performed the psychosocial evaluation and coordinate individual, group, and family interventions. The resident will be evaluated on a routine basis by the attending psychiatrist who will coordinate with the interdisciplinary treatment plan.

Estimated Length of Stay:

300 days.

Initial Discharge Plan:

Upon indication that the resident can be manages at a lower level of care in the community; he will be evaluated for discharge.

Total time spent 45 minutes; greater 50% of this time was spent providing counseling and coordination of care.

Recreational Therapy

Resident Assessments

On July 14, 2015, the recreational therapy intern conducted the three assessments that are required by the facility. The assessments are expected to be done within the first 7 days of the resident admitting to the program. This resident had been in this program for 5 days when the assessments were conducted. The evaluation was done in a conference room away from the other adolescent residents.

The first assessment was the Recreational Therapy Assessment that was built by the recreational therapy supervisor. The items revolve around these therapeutic areas: decision making/problem solving, communication/socialization, coping/frustration/resiliency, and attention/memory/orientation. The first part of the assessment is a Likert scale and the second are narrative questions. The results of this assessment are recorded by an RS narrative summary that delineates the residents affect, participation in the interview, and behaviors observed by the RS. This resident’s summary is the following:

‘Resident presented an insightful affect when answering items. He sat quietly and calmly throughout the assessment. He answered low scores for items that questioned self-confidence. He relayed to RS that he would like to learn how to deal with “stress”.’

The second assessment that was conducted was the Resiliency Attitudes and Skills Profile (RASP). This measures and has subscores for creativity, humor, independence, initiative, insight, relationships, and values orientation. The residents scored particularly low for his subscores of creativity, independence, and insight.
The third assessment that the recreational therapy program requires is the Comprehensive Evaluation in Recreational Therapy- Psych Revised (CERT-PR). The recreational therapist is supposed to write up this evaluation based on observations of the resident. There are three categories (General, Individual, and Group Interaction) that are scored separately then an overall score. The results showed that his individual and group interaction were ‘problematic’ and needed improvement.

Due to the nature of this program, the intern would not be working at the facility when that resident would be discharged. To show results of some sort, two extra assessments were conducted on July 7, 2015. From three assessments already taken, it was determined that the residents’ goal should be to increase self-worth. The two assessments conducted were the Social Empowerment and Trust scale (SET) and the Rosenberg Self Esteem scale.

The SET scale revealed that this resident has a problem with bonding/cohesion, empowerment, and awareness of others. His total score was an 85.
The Rosenberg scale resulted in a 22, which is about average for this scale.

During both of these assessments, the resident presented a disinterested affect and a lack of insight. For a lot of his answers, his behaviors and actions towards his treatment did not match.

Bipolar Disorder

Definition

Bipolar disorder is a brain disorder that is marked by periods of elation and depression. This disorder of the brain causes unusual shifts in mood, energy, and activity levels. Children with this disorder tend to have intense emotional states that occur in distinct periods called mood episodes. Each episode represents a huge change from the individual’s normal mood and behavior (National Institute of Mental Health, 2012). Bipolar disorder makes it extremely difficult for the individual to carry out day-to-day tasks. These tasks may include things like hanging out with friends or going to school. The symptoms of this disorder can sometimes be very severe. The ups and downs that are experienced are very different than the normal ups and downs that someone would experience every once in a while. The symptoms can lead to damaged relationships, poor school performance, and sometimes suicide (National Institute of Mental Health, 2012).

There is currently no known cure for bipolar disorder. However, there is treatment for this disorder that allows the individual to have a full and productive life. The symptoms of bipolar disorder tend to develop in the late teen years and early adulthood, although some individuals do begin to display symptoms during childhood. Children are six times more likely to develop the illness if a parent or sibling has it, because bipolar disorder tends to run in families due to a genetic component (National Institute of Mental Health, 2012).

According to the DSM-5, there are four primary diagnoses for bipolar disorder. These diagnoses include: bipolar I disorder, bipolar II disorder, bipolar disorder not otherwise specified (BP-NOS), and cyclothymic disorder (American Psychiatric Association, 2013). According to the National Institute of Mental Health, bipolar I disorder is characterized by manic or mixed episodes. These episodes must persist for at least seven days. Manic symptoms may occur that are very severe and they could possibly lead to hospitalization of the individual. Usually depressive episodes occur that last at least two weeks. In addition, bipolar II disorder is characterized by depressive episodes and hypomania episodes that occur in a pattern. Individuals do not experience full-blown or mixed episodes. Bipolar disorder not otherwise specified (BP-NOS) is characterized by symptoms of the illness that do not meet the diagnostic criteria for bipolar disorder I or bipolar disorder II. The symptoms that are shown are out of the individuals normal behavior range, as stated by the National Institute of Mental Health. Lastly, cyclothymic disorder is a mild form of bipolar disorder. It is characterized by episodes of hypomania and mild depression. These symptoms last for at least two years. These symptoms do not meet the criteria for any other type of bipolar disorder (National Institute of Mental Health, 2012).

Demographic Information

Overall, bipolar disorder affects 2 percent of the world population (DynaMed Plus, 2015). The National Comorbidity study reported a lifetime prevalence of nearly 4 percent for bipolar disorder (Centers for Disease Control and Prevention, 2013). Bipolar disorder is less common in men than in women. The ratio is approximately two men to every three women.

The onset age of bipolar disorder tends to occur at a younger age for men. According to the Center for Disease Control and Prevention, the median onset age is typically twenty-five years of age (2013). According to Kathleen Merikangas and the National Institute of Mental Health, about 3.9 percent of adults meet criteria for bipolar disorder in their lifetime. 2.5 percent of children meet the criteria in their lifetime. The rates of bipolar disorder increase with age. 2.1 percent of younger teens reported symptoms, while 3.1 percent of older teens reported symptoms of bipolar disorder (National Institute of Mental Health, 2012).

Strengths of Client

My client’s strengths are evident in his attitudes towards treatment. It appears to me that he is ready for treatment. My client also really enjoys being in good health, which makes his attitude towards treatment more positive. I believe that this positive attitude will be very beneficial during his treatment. He is also taking traditional classes at school. I see this as strength because he is still able to be around his peers and people his age. This gives him the opportunity to be social and increase his social skills. He is developmentally able to be in these classes, we just need to address the issues that are holding him back from doing his best. This type of structure could potentially be very beneficial for my client.

Needs of Client

My client needs more individualized help in the school setting. He is having trouble keeping up with classes and maintaining his grades. He needs to have a very structured setting with other accommodations to ensure that he is doing his best. Bipolar disorder makes it hard for students to function. It is extremely hard for them to stay focused (Samuel, 2006.) I think that it would be beneficial to teach my client skills that he could use to help cope with his symptoms while he is in school.
My client has a history of high risk behaviors. He needs assistance managing his behaviors before he experiences and engages in those types of behaviors again. According to the National Institute of Mental Health, people with bipolar disorder tend to engage in extremely high risk behaviors that can lead to more serious issues (2012). This can also be due to the fact that my client is also diagnosed with ADHD. Bipolar disorder and ADHD tend to co-occur (Carlson, 2012).

Environmental Barriers

Being in OCS custody is a barrier for my client. He is not with anyone that he knows and is close with. My client does not really have a steady support system, as mentioned earlier. Having a good support system could be very helpful for him in treatment. Results from a study show that people in family therapy respond better to treatment (National Institute of Mental Health, 2008).
My client has witnessed domestic violence and neglect in his life. This can affect the way that he perceives things. He might think that his behaviors are okay because he has witnessed them before. This increases the likelihood that he would engage in these behaviors. Studies show that people who witness or experience violent events are more likely to act violently (American Journal of Public Health, 2002).

Cultural Information

My client is fifteen years old. Most individuals do not show signs and symptoms of bipolar disorder until their late teenage years or early adult years (National Institute of Mental Health, 2012). However, according to the National Institute of Mental Health, some children can begin to show signs and symptoms as well (2012).
My client is a male. Bipolar disorder tends to be less common in men than in women (Centers for Disease Control and Prevention, 2013). According to the National Institute of Mental Health, the median the ratio of bipolar disorder is two men to every three women (2012). So, for every three women diagnosed there are two men that are also diagnosed.
My client is Native American and is from the northwest.
It is suspected that my client was exposed to alcohol in utero.
My client’s intelligence level is considered below average.

Efficacy Research