CNDV 5327 LU Week 2 Health & Medical Bipolar Disorder II Eve Case Study

Case Study 2 Instructions

Make sure to fully respond to each question and to use the rubric to guide your writing (the rubric is used to determine your grade). Your assignments should be written in accordance with APA 6^th edition guidelines and contain two professional sources (your text-book may count as one of your resources). Although there is no minimum page length requirement for this assignment, you will likely write a minimum of four pages to full address all of the prompts.

Case Scenario

The Case of Eve

Eve is a thirty-two-year-old woman who comes to the therapist for treatment of depression. Her current symptoms include the following: depressed mood, apathy, anhedonia, hypersomnia, significant daytime fatigue, suicidal ideations, and low frustration tolerance. She has experienced five prior episodes of depression. The symptom picture was much the same during each episode, though in this most recent episode she reports that her suicidal thoughts have increased. She also is increasingly pessimistic about psychiatric treatment being helpful for her.

Eve’s first episode occurred at the age of twenty-one and the second at age twenty-five. During these first two episodes of depression, each of which lasted approximately eight to nine months, she was functional but seriously depressed. She did not seek treatment; apparently in both cases she eventually experienced spontaneous remissions. In the next episode (her third, at age 27), she did see a psychotherapist and reports that it was somewhat helpful, but the treatment (psychotherapy alone) did not resolve her depression. Again she eventually recovered after twelve months. Again, it was likely a spontaneous remission.

Episode number four (age 29): Eve was treated by her primary care physician with Zoloft. She started this medication at a dose of 50 mg qd and she did tolerate it. After one month on this dose the dose was increased at first to 100 mg and then to 150 mg. After 3 months during which she did not show any improvement she was switched to Wellbutrin. Again she started with a low dose and was eventually increased to a dose of 300 mg qd. On both the Zoloft and the Wellbutrin, there was no significant improvement, but she remembers that she did experience increased irritability. Since the medication was not effective, she simply stopped taking it (four months into treatment). Eve continued to be depressed but somehow tolerated it and never talked to her doctor about it again. By twelve months her depression lifted.

Episode number five (age 30): This time Eve saw a psychiatrist and was tried on a number of different drugs: Effexor (up to 300 mg); Wellbutrin added to Effexor (doses in the therapeutic range). On Wellbutrin and Effexor she showed a 10% reduction in symptoms on the Hamilton Depression Rating Scale, but her slight improvement was accompanied by increased irritability, and that was the reason she stopped this medication combination after six weeks. The next medication she was prescribed was Remeron (which she stopped after five days due to excessive daytime sedation). Next she was tried on Effexor and lithium (she discontinued the lithium after three weeks due to sedation and nausea). Before stopping she had attained a blood level of 0.6 and no noticeable improvement. Finally, she was prescribed Cymbalta; again, not successful. Her psychiatrist diagnosed her as having treatment-resistant major depression without psychotic symptoms.

She now seeks treatment for her sixth episode of depression, which began three months ago and has gotten increasingly more severe.

Eve denies any history of psychotic symptoms, mania or hypomania, suicide attempts, or significant abuse of alcohol or other recreational drugs. She does drink four cups of coffee a day, attempting to stay alert and combat her constant fatigue. She takes a low dose of Inderal to treat a “mild case of hypertension.” She was started on this medication about three months prior to her current episode of depression. She says that she has no other medical problems.

In her first episode the break-up of a romantic relationship seems to have triggered the depressive episode. This was the case again in her second episode. However, in all later episodes there were no noticeable psychosocial stressors occurring prior to the depression. The depressions seemed to “come out of the blue.” She is currently married, in a stable and supportive relationship with her husband, and works as a university librarian.

Family history is significant. Her maternal grandmother (someone she never met) had had a number of psychiatric hospitalizations and she killed herself when she was twenty-nine years old. One cousin has had a “nervous breakdown.” Eve does not know any details about this. A great aunt was a severe alcoholic, and mother suffers from moderately severe chronic depression.

Eve says that now she feels desperate and is plagued by recurring and intense suicidal impulses.

Directions: Please respond to the following questions. All papers should be written in APA format.

Questions

1.  Make a diagnosis (and mention possible diagnoses/diagnoses to rule out), and explain the rationale for the diagnosis.

2. What are the points in favor of a bipolar II diagnosis?

3.What might account for the failure to respond to any of the prior treatments?

4. Given the diagnosis you have made, describe your medication treatment strategies. Discuss not only initial choices of medications but also your next-step strategy and why you’ve chosen it. (In doing so, be sure to provide a rationale for your choices.) What questions should be addressed about the class of medications that is chosen (e.g., mood stabilizers)?

• This assignment is worth 100 points.
  • All assignments should be written in APA format. Please include a title page, the body of your paper, and a reference page. All papers should include an introduction and conclusion.
  • Submit the assignment by 11:59 CST on Day 7 of the week.

Assignment Rubric

Criteria	Well Developed (A to High A)	Developed (B to Low A)	Emerging (C to Low B)	Undeveloped (Less than a C)
Question 1: 15 pts Make a diagnosis (and mention possible diagnoses/diagnoses to rule out), Explain the rationale for the diagnosis.	15 points The correct diagnosis was clearly identified. Possible diagnoses to rule out were identified. Rationale for diagnosis was explained and pointed to the diagnosis.	13-14 points The correct diagnosis was clearly identified. Diagnoses to rule out were identified Rationale for diagnosis was explained.	11-12 points A diagnosis was identified. Diagnoses to rule out may or may not have been present. Rationale for diagnosis was present.	0-10 points A diagnosis was present but diagnoses to rule out may or may not have been present. Diagnostic rationale may not point to diagnosis or is missing.
Question 2: 15 pts What are the points in favor of a bipolar II diagnosis?	15 points Hypomanic episode and depressive episodes are identified and not explained by ruling out disorders. Clinical distress is present. No manic episodes identified.	13-14 points Hypomanic episode and depressive episodes are identified and not explained by ruling out disorders. Clinical distress is present.	11-12 points Hypomanic episode and depressive episodes are identified. Clinical distress is present.	0-10 points Hypomanic episode and depressive episodes are vaguely identified or missing. Clinical distress may or may not be noted.
Question 3: 15pts What might account for the failure to respond to any of the prior treatments?	15 points Previous treatments are all identified and discussed. Rationale for treatment is multi-factorial and direct links applied to previous treatments.	13-14 points Previous treatments are all identified and discussed. Rationale is present with direct links applied to previous treatments.	11-12 points Some previous treatments are identified and discussed. Rationale for treatment failure is discussed.	0-10 points Some previous treatments are discussed. Rationale for treatment failure may or may not be present.
Question 4: 30 pts a.   Given the diagnosis you have made, describe your medication treatment strategies. Discuss not only initial choices of medications but also your next-step strategy and why you’ve chosen it. (In doing so, be sure to provide a rationale for your choices.) b.   What questions should be addressed about the class of medications that is chosen (e.g., mood stabilizers)?	29-30 points Diagnosis is stated and medication treatment strategies are fully discussed. Medications are identified and rationale for next-step use presented and linked to therapeutic interventions. At least five medication questions are thoroughly addressed.	25-28 points Diagnosis is stated and medication treatment strategies are discussed. Medications and rationale for next-step use presented with suggestions for accompanying therapeutic interventions. Two to four medication questions are thoroughly addressed.	22-24 points Diagnosis and medication treatment strategies are incompletely addressed. Rationale for next-step use is incomplete and may not be associated with any suggestions for therapeutic interventions. One or more medication questions are incompletely addressed.	0-21 points Medication treatment strategies are present. Rationale for next-step use is vague or is missing. Accompanying therapeutic interventions may or may not be present. Medication questions are incomplete or absent.
Writing Mechanics and APA Format: 15 points	15 points No more than three grammatical, spelling, punctuation, and/or APA errors. Clarity of paper not influenced by errors.	13-14 points More than three grammatical, spelling, punctuation, or APA errors. Clarity of paper was not strongly influenced by the errors.	11-12 points More than three grammatical, spelling, punctuation, or APA errors that had a negative influence on the clarity of the paper.	0-10 points More than three grammatical, spelling, punctuation, or APA errors that had a strong negative influence on the clarity of the paper.
Sources: 10 points	10 points 2 professional sources or more are used throughout the paper as appropriate to thoroughly support ideas, and are documented in the references list.	9 points 1-2 professional sources are used to adequately support ideas and are documented in the reference list.	7 points 1 professional source is used to partially support ideas and is documented in the reference list.	0-6 points 1 source or less was used. Ideas were insufficiently supported.
Total: 100 points

Eve’s background

The critique will deliver a theoretical diagnosis and examination of therapeutic founded on a patient analysis of Eve. The vignette expresses the patient as a 32-year-old female pursuing therapy for a routine of 6 depressive spells that first began about 11 years back at year 21 following the ending of a romantic affinity. Her depressive outbreaks seem to embody signs of a depressed attitude, disinterestedness, reduced capacity to discern enjoyment, extreme daytime drowsiness and exhaustion, suicidal thoughts, and increased irritability. After several attempts to resolve the episodes with psychotherapy and trials with various antidepressants and mood stabilizing medications, her attacks continue to cause considerable grief and impair her quality of life.

First diagnostic evaluation

Eve is most probably experiencing bipolar II syndrome based on her clinical presentation, family history of mental health, and record of several unsuccessful therapies. Major depressive disorder (MDD) and bipolar II share several clinical guidelines, making it difficult for a specialist to distinguish them (Preston, 2021). Their chances are that clients may not always be mindful of their increased and dysfunctional emotionality and might not be particularly open and honest with this personal data. Eve’s non Openness is because hypomania is a state where users may feel particularly viable or productive and not display it as a prospective symptom. Nonetheless, hypomanic episodes can be more brutal to identify in clients (Singh & Rajput, 2006). Differential examinations to evaluate MDD include attention deficit disorders, schizophrenia spectrum ailments, panic or anxiety conditions, cyclothymic diseases, substance use conditions, personality disorders, and bipolar conditions (American Psychiatric Association, 2013).

Founded on Eve’s symptom exhibition, the most crucial differential diagnoses to eradicate are probable MDD, cyclothymic disorder, and substance usage disorder (APA, 2013). The cyclothymic condition can be eliminated instantly, as demonstrated by the existence of a bonafide significant depressive spell. Drug abuse infection is not feasible based on facts obtainable exceeding rejection of alcohol or drug misuse and an outlying genetic link to a grand aunt. She had an intense alcohol problem (APA, 2013). MDD can be better differentiated from bipolar II disorder by administering a screening or assessment tool, like the Mood Disorder Questionnaire, which can help clinicians identify or eliminate bipolar disorder as a possible diagnosis (Singh & Rajput, 2006). The following signs, nevertheless, suggest that MDD can be ruled out for the following purposes:

1. Antidepressant medications failed to alleviate Eve’s illness, which is strongly associated with a sign of bipolar disorder.
2. Extreme tiredness and sleeplessness are both signs of bipolar illness.
3. There is a high likelihood that bipolar illness has a parental hereditary component (Preston, 2021).

Supporting indication

According to an assessment of her behaviors to those listed in The Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013), Eve probably satisfies the following bipolar II condition diagnostic criteria,

1. Unstable episodes.
2. A stretch of at least four days during which there is an extraordinary rise in energy and a change in mood.
3. Higher self-esteem, a lower need for relaxation, being more extroverted, and a rise in goal-directed activities are four notable mood characteristics (caused by the unpleasant mood state).
4. A change in operating between incidents is discernible.
5. Changes in mood and performance that other people can detect.
6. Not enough extreme symptoms to require hospitalization or to seriously hinder doing daily duties.
7. Drugs did not bring on the incident.

Incident of severe depression:

1. A persistently gloomy mood decreased interest in or enjoyment of activities, excessive sleepiness, exhaustion, and repeated suicidal tendencies are five or more symptoms that endure for two weeks or more.
2. Substantial deterioration of social functioning and operationally.
3. Drugs did not bring on the incident.

Bipolar II Disorder:

1. Partially one irrationality state and one severe depressive phase have occurred.
2. There is no proof or history of mania.
3. There is no more straightforward explanation for episodes than schizophrenia-associated illnesses.
4. Depression signs transition between hallucinosis and therapeutically, and severe functional disorders are brought on by depression.

Additional supporting factors

Eve’s condition has characteristics that are consistent with bipolar II illness, including the following:

1. Age (21 years old) when symptoms first appeared.
2. Uncertain mood swings that frequently occur in a sequence.
3. Hypomanic indicators are of no significance as they are less likely to be detected as impairing the person themself. Depressive moods dominate the symptomatology and are substantially more widespread and incapacitating.
4. Bipolar II disease has a significant indication of occurring due to genetic preconceptions and the father’s side history of depression (Singh & Rajput, 2006).

Treatment history analysis

Eve’s prior diagnoses of MDD and therapy-resistive MDD are likely related to variables that may have led to her lack of responsiveness to pharmacotherapeutic treatments. In the past, she has primarily received antidepressant prescriptions (such as Cymbalta, Effexor, Zoloft, Remeron, and Wellbutrin), which are known to be unhelpful for patients with bipolar illness (Preston, 2021). Lithium, a short mood stabilizer, was withdrawn after three days due to inefficiency and terrible detrimental reactions. The strategy created to manage MDD rather than bipolar II disease may have made counseling methods ineffectual. Eve’s poor response to therapy is caused by the interaction of all of these elements.

Recommendations for treatment

Through this specific diagnosis, the therapeutic approach has to be revised. The best way to treat bipolar illnesses is with drugs because data demonstrates that they are primarily biological (Singh & Rajput, 2006). Bipolar II disorder can benefit from psychotherapy combined with pharmacological treatments (Preston, 2021). It has been shown that cognitive behavioral therapy, group counseling, psychotherapy, and family counseling benefit these people. However, prescriptions remain the standard treatment for bipolar anxiety and depression (Preston, 2021).

As it will be down to the treating doctor to determine the dose after taking Eve’s existing medicines, age, weight, height, and any medical conditions must be considered. An antipsychotic medication called aripiprazole acts to stabilize neurotransmission.

Often, lithium is the first-line option for mood stabilizers. Still, given Eve’s past experiences with its inefficiency and unpleasant adverse effects, the best course of action is to put her back to the doctor so that she may be reviewed for Divalproex, a regularly recommended drug. Divalproex is an antipsychotic medication with anticonvulsant effects comparable to lithium. Still, lesser side effects, no danger of overdose, and a more comprehensive therapeutic range make it a potentially excellent fit for Eve’s requirements (Preston, 2021).

If Eve does not perform this alternate anticonvulsant, quetiapine is another medication recommended for use when patients have more extreme bipolar II condition psychological distress (Preston, 2021). The Food and Drug Administration (FDA) has authorized quetiapine, a compensatory schizophrenia medication, to address bipolar depression because it has a lower proportion of the extrapyramidal detrimental reactions frequently seen with antipsychotic medicines (McDonald & Cook, 2021).

The psychoeducation component of Eve’s therapy program is crucial. Counselors can spend additional interaction with patients and impart knowledge that can promote compliance with treatment schedules and guarantee safe usage. It might be indispensable to advise a customer about the pharmacokinetic and pharmacodynamic characteristics of the prescriptions they are using when transferring them to a new medication. Including the following points in these discussions can help patients benefit the most from their therapy:

1. A classification of the medicine and a statement of the condition is used for treatment.
2. Body’s reactions and how it benefits the client.
3. Dosage details include the dose, usage, when, how it should be administered, storage instructions, and how the medicine looks.
4. Common adverse effects, contraindications, and what to do if they occur.
5. Possible relations with other drugs or meals.
6. The duration to experience the outcomes of the prescription.

Ethical and legal considerations

A therapist must stay up to date on pertinent legislation and moral standards regarding medical and counseling at the national, state, and operational levels since they influence human health and the welfare of society. Following the American Counseling Association’s Code of Ethics (Francis, 2020), it is standard protocol for practitioners to safeguard the health of the communities by maintaining that counselors provide accurate assessments, create treatment options in consultation with healthcare experts, and make referrals to healthcare practitioners when necessary. Working as a registered, licensed therapist within the bounds of professional competence and sending patients to qualified prescribers rather than issuing prescriptions.

The Drug Enforcement Agency (DEA) is in charge of regulating the proper use of prescription medications and guarding against the risk that might result from abusing them or using illegal narcotics. As a consultant in the medical community, offering precise and reliable evaluations and recommendations for drug assessment. However, help the DEA and the community’s general health by preventing the prescription of harmful pharmaceuticals to people. It will also be the psychiatrist’s responsibility to inform the appropriate people of any knowledge of another doctor or prescription who may not be following their standards of conduct and engaging in unlawful conduct to prevent future harm to their clients and neighborhoods (McDonald & Cook, 2021). Substance abuse and misuse are significant problems that constantly impact America in avoidable ways.

Conclusion

Eve’s case raises concurrency issues. The diagnosis of the patient requires prudence on the part of the counselor. One of the primary goals of Eve’s appointments is to teach her the signs of hypomania so she can start noting and reporting occurrences of the condition. Other areas of concentration include teaching clients about bipolar II disease and Eve’s new counseling approach, ECT, and CBT.

References

American Psychiatric Association Division of Research. (2013). Highlights of changes from DSM-iv to DSM-5: Somatic symptoms and related disorders. Focus, 11(4), 525-527.

Francis, P. C. (2020). Legal and ethical issues in college counseling.

McDonald, K. E., & Cook, A. (2021). APA Style: A Foundation for Advocacy in Counseling. The Journal of Counselor Preparation and Supervision, 14(1), 8.

Preston, J. D., O’Neal, J. H., Talaga, M. C., & Moore, B. A. (2021). Handbook of clinical psychopharmacology for therapists. New Harbinger Publications.

Singh, T., & Rajput, M. (2006). Misdiagnosis of bipolar disorder. Psychiatry (Edgmont), 3(10), 57.