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Case Study: Gina, Bipolar Disorder

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William Leonard

on 8 February 2018

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Transcript of Case Study: Gina, Bipolar Disorder

Case Study: Gina, Bipolar Disorder
& Diathesis Stress Model

Diathesis
Disorder
Bipolar Disorder
Stress
Biological and /or psychological vulnerability

Biological vulnerability:
genetic
factors and / or
brain dysfunction

Psychological vulnerability:
dysfunctional
interpretation and reaction to environmental factors.
Stress: Environmental factors (stressors)


Above average student.
Did not seem to have any unusual psychological problems
A popular girl who had many friends.



At about
age 17
, while a member of the school theater group her behavior became increasingly
bizarre.

Giddy and talkative
she approached strangers for rambling conversations, telling some that she was a
famous actress
.
Once, she actually burst out in song,
Background History
The Incident
Manic Episode
Depression Episode
Cast members were distancing themselves
Gina’s joy shifted to
paranoia,
other students were plotting against her, trying to undermine her road to
fame and glory
.
She became
withdrawn
.
She became
depressed
, crying all the time and refusing to go to school
she believed that everyone hated her and she
wished she were dead
Sophomore Year: Second Episode of Depression
Another depressive episode led her doctor to
increase
her
antidepressant
medication
The increased dose of antidepressant was likely responsible for
triggering
her second manic episode,
Second Manic Episode
Spend l
arge amounts of time
at the library, reading astronomy materials and becoming
extremely excited
about the idea of interplanetary travel.
Eventually she spent
3 days
in her room almost
without sleeping
Plotting voyages across the heavens and developing
grandiose plans
for colonizing the solar system

Triggered Mania Episode
Another hospitalization
Treatment: Medication
Lithium carbonate (Lithium)
Lithium is a silvery white metallic element that occurs in nature as a mineral salt.

Medication Noncompliance, Why?
Free of manic episodes
But felt she had lost her spark; her
emotions felt dulled
.
Longed
for a few mild highs in her emotional life, a feeling of
excitement
or of “just being alive” .
Medication Noncompliance, Consequences?
Gina would
stop
taking the medications
Became more
vulnerable
to manic episodes and the depression that often followed.
Hospitalized
DSM 5: Manic Episode
A. For 1 week or more, person displays
a continually abnormal, inflated, unrestrained, or irritable
mood
as well as
continually heightened
energy or activity
, for most of every day.
B. Person also experiences at least 3 of the following symptoms:   
Grandiosity
or overblown self-esteem    
Reduced sleep need   
Increased
talkativeness
, or drive to continue talking   
 
Rapidly shifting ideas
or the sense that one’s thoughts are moving very fast   
Attention pulled
in many directions   
Heightened activity or agitated movements    
Excessive pursuit of
risky
and potentially problematic activities.
C. Significant impairment in social or occupational functioning. (Based on APA, 2013.)

DSM 5: Bipolar I Disorder
1. Occurrence of a
manic
episode.
2. Hypomanic or
major depressive
episodes
may

precede or follow the manic episode.
(Based on APA, 2013.)

Gina’s Manic Episodes: Criterion A
Inflated Mood
: The first sign was usually a feeling of
happiness
that gradually grew to a
glorious outlook
on life.
Heightened energy or activity:
Increased talkativeness with strangers and friends
Shopping sprees
Increased sexual activity

Gina’s Manic Episodes: Criterion B
Grandiosity
or overblown self-esteem: felt immensely pleased, considering herself the smartest, sexiest, most talented woman alive.
Increased talkativeness
: almost unbearably outgoing and friendly, chatting with strangers on the bus or subway and calling up friends in search of stimulating conversation late at night

Gina’s Manic Episodes: Criterion B
Excessive pursuit of risky and potentially problematic activities
:
Gina went
shopping
for new clothes, often spending large amounts of money,
As the euphoric feelings progressed, her behavior crossed acceptable boundaries. Of particular concern were her
sexual impulses.

Manic Episode: Psychosis
As her mania progressed, her
contact with reality
would increasingly
slip away
.
She was capable of developing many
grandiose
ideas.
She once became convinced that she had a natural talent for
interior design

Gina’s Depressive Episodes
She
lost all interest
in normal activities
Called-in sick to work
Slept
16 hours each day.
Even when awake could barely leave bed.
She spent most of her conscious hours mindlessly surfing the Internet,
sobbing
, and thinking she was a
miserable failure
at every aspect of life.

Impairment: Social Relationships

It was very hard
to stay friends
with Gina
As she became increasingly
manic,
friends would become
confused, appalled
, and ultimately
frightened.

During her
depression
, they might feel pulled down by her misery and pain.
After witnessing one of her manic or depressive episodes, some friends would decide to
end the relationship.

Distress
During depressive episodes Gina perceived herself to be a
miserable failure
at every aspect of life.
Gina would be
embarrassed and humiliated
by how she might have acted during a
manic
episode, she later found it hard to feel comfortable, or even respectable, in the presence of those who had witnessed her
bizarre
behaviors.
Emotional Roller Coaster
Gina rode an emotional roller coaster
Her
manic
episodes were more
frequent
than her depressive episodes
More of an
obstacle
to her professional and social goals
Impairment: interfering with daily functioning

Between Mood Episodes
Gina was
intelligent, responsible, serious
about her work, and considered a capable sales representative by her employer.
She was not completely free of difficulties.
She suffered from chronic
low self-esteem
.

Treatment: Lithium Balance
A balance between the drug’s
therapeutic efficacy
and its unpleasant
side effects
Need to
maximize the anti-manic benefit
of medication while permitting a
greater range of emotional feeling.
Medication: Lifetime Treatment
Accept the reality that they have a lifelong disorder and that they probably will have to be on medications for
most of their life
.
Treatment: Empathy to Compliance
Empathize with Gina’s
spotty record
of medication compliance.
Noted that the medications often had the effect of
reducing
even a normal sense of
high spirits
, and, many patients were tempted to
omit
their medications occasionally.
The First Year of Treatment :
The Roller Coaster Continues
Gina’s mood was
stabilized
After about 4 months , Gina began to grow increasingly more
cynical
about her
“boring” life.
Finally, she decided to
stop
taking her Lithium.
Subsequently, Gina experienced
mania and depression
Treatment: Insight Psychotherapy
Gina was like a
rebellious adolescent
, who saw taking the medicine as something
imposed
on her
The psychiatrist suggested that Gina might benefit from some
psychotherapy
to help sort out her feelings.
Psychotherapy, she explained, might also be helpful with some of Gina’s other concerns, her
problems with relationships.

The Second Year of Treatment: Psychotherapy & Insight
12 months of intensive
insight-oriented
therapy
Gina recognize her
resentment
of her parents
She was running her life much like an
adolescent
whose main goal was
rebellion
against her parents.
She needed to
stop
making rebellion against her parents the primary guiding force of her life.

Acceptance: Medication
Gina recognized that the medication could
control
her manic and depressive episodes and help her to live an
independent
life.
Could she
accept the trade-off
that the medication required, including the
loss
of the
excitement
that manic periods
initially
produced.
Gina came to
accept
that the
advantages
of the Lithium outweighed its disadvantages.

The 3rd Through 7th Years
By the 3rd year of treatment, Gina’s life began to
stabilize.
She developed
independence
from her parents and acquired a
steady boyfriend
for the first time.
Gina was able to make greater
progress
in her
professional life.
She was eventually promoted to regional manager.

Treatment & Life Success
As Gina experienced the
pride of professional success
, the pleasures derived from
manic
episodes seemed
less important
to her.
This helped her to
take her medications
even more reliably as time progressed.
After
7 years
of treatment with Dr. Rabb, Gina
reduced
her visits to the psychiatrist to just a few times per year, while continuing to consult with
Dr. Kohl,
the psychologist,
periodically.
Long Term Treatment
Over the
next 10 years
, Gina stopped seeing Dr. Kohl but continued to see Dr. Rabb for her medication needs.
Over the years, she obtained a
business degree
,
advanced
further in her
profession
, and developed a
long-term romance.
At last, her emotions—and her life—had indeed
calmed
down

What Was Gina's Diathesis?
Biological Diathesis: Genetics
Family, twin, and adoption studies all support a
strong
familial and genetic component (Barnett & Smoller, 2009).
Estimates of the
heritability
of bipolar disorder range from
59 to 87%
(McGuffin, et al., 2003).
Up to
87%
of the
risk
for bipolar disorder is due to
genetic
factors with the remaining risk due to environmental factors.
Did she have an apparent biological or psychological
predisposition or vulnerability for Bipolar Disorder?
Brain Dysfunction
What Was Gina's Stress(or)?
Did she experience specific and signifucant stressors
that would lead to bipolar disorder?
Psychological Diathesis
Did Gina experience a psychological predisposition
or vulnerability to bipolar disorder?
Biological and environmental factors
interact
to determine the
likelihood
that a person will exhibit
abnormal
behavior.

Diathesis Stress Model
Stress:
negative emotional experience
accompanied by biochemical, physiological, cognitive, and behavioral responses aimed at changing or adjusting to the stressor
Stressor: any
event
that produces tension or other negative emotions
What theoretical perspectives are applicable
in this case study?
Biological Perspective, biological:
Genetic
component of Bipolar Disorder
Medication
used in treatment
What theoretical perspectives are applicable
in this case study?
Psychodynamic Perspective, psychological
Unresolved
resentment toward her
parents
affected
current
relationships with them and others
Gina behaved as a
rebellous
adolescent
Humanistic Perspective, psychosocial
Therapist-client
therapeutic relationship
Dr. Rabb’s
empathy
with Gina’s struggle with medication compliance
Socio-Cultural Perspective, social
Socio:
social suppor
t from parents and therapists

DSM 5: Major Depressive Episode
A.
Five or more
of the following symptoms have been present for a
2-week period
and represent a change in previous functioning. At least one of the symptoms is (1) depressed mood or (2) loss of interest or pleasure.
1. Depressed mood for the majority of each day as indicated by feeling sad, empty, or hopeless.
2. Decrease in enjoyment or interest across most activities for the majority of each day.
3. Considerable weight change or appetite change.
4. Daily insomnia or hypersomnia.
5. Daily agitation or decrease in motor activity.
6. Daily fatigue or lethargy.
7. Daily feelings of worthlessness or excessive guilt.
8. Daily reduction in concentration or decisiveness.
9. Repeated focus on death or suicide, a suicide plan, or a suicide attempt.
B. Significant distress or impairment in social, occupation, or other important areas of functioning.
(Based on APA, 2013.)

No apprent psychological diathesis
No apparent significant stressor
A special problem with bipolar disorder was the
pleasure
that patients often would get from their
manic
symptoms.
The patients might be tempted to
discontinue
the drug to
get the high.

Explained that the first step was to
maximize
the
anti-manic benefit
of medication while permitting a
greater range
of emotional feeling. 
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