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Psychological disorders are referred to as mental health disorders that define abnormalities of mind, resulting in uninterrupted behavioural patterns, affecting day-to-day life and functions. One of important psychological disorders is a bipolar disorder that is also known as manic depression. It is connected to mood swings episodes that range from low to manic high. This report is going to do a case study analysis on bipolar disorder, where it will discuss the problem with help of DSM-5 criteria. Secondly, it will state cause and treatment of selected disorders with help of psychological theory and research. Lastly, it will discuss ethical issues research may experience while working with individuals with this psychological issue.
DSM 5 symptoms for mania
Evidence from the case study
1.High mood swings, which involve emotional highs or hypomania and depression
Mark, Dorothy’s husband, mentioned that these symptoms or behaviour last for many days or a week. Regarding this, DSM-5 Criteria for Bipolar Disorder mentions that besides decreased need for sleep, other major symptoms during this period are increased talkativeness and racing thoughts (Psychiatry.org, 2021)
2. Decreased need of sleep, Flight of ideas, more talkative nature
Dorothy could not sleep, and she explained that she had not everything to help herself as she went to bed at the same time every night and switched off their TV and phone a couple of hours before bedtime
3. Symptoms do not meet criteria for a mixed period
In case of hypomania, an individual’s mood must last for at least four consecutive days, and it can be present most of day and almost every day (Psycom.net, 2020). In this period, individuals can also experience some more symptoms.
4. Mood disturbance at a severe level
Mark stated that sometimes Dorothy becomes highly energetic and cannot stop talking. For example, Dorothy has huge ideas, she insists on doing things straight away for trying and achieving them, and during this phase, no one can stop her
5. Symptoms did not caused due to direct psychological effects of substances
Dorothy experienced racing thoughts, one day, she felt urgent to let her institute know about her insights; however, she felt very upset when one of her colleagues told her that she was spouting nonsense
Table 1: DSM 5 symptoms for mania
In this context, DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) stated that for being diagnosed with bipolar disorder, an individual had faced at least one episode of hypomania or mania (Psychiatry.org, 2021). Regarding mania, an individual can experience it for 1-week and can be present majority of day. However, one of important ones is decreased need regarding sleep, and it represents significant change within behaviour. Novick& Swartz (2019) explained that episodes of depression, hypomania, and mania are sub-threshold symptoms, leading to morbidity and mortality of patients with bipolar disorder. Additionally, Mendez, Parand&Akhlaghipour (2020) explained that people with bipolar disorder have three key symptoms: decreased need regarding sleep, inflated self-esteem, and being more talkative than usual and feeling pressure for continuous talking.
Information provided by Mark indicates similar symptoms to DSM-5. Additionally, research also found that different diagnostic procedures have been present regarding different symptoms of bipolar disorder. First presentation about patients can be similar to different psychotic and mood disorders, such as schizoaffective, schizophrenia, and major depression (Rhee et al. 2020). Additionally, Post (2020) stated that symptoms of bipolar disorder could include impulsivity, truancy, and recklessness. By agreeing to this, Dailey &Saadabadi (2018) explained that bipolar disorder is categorized into three categories: mania, hypomania, and major depression. In mania, symptoms include rapid speech, decreased sleep, racing thoughts, distractibility, and talkativeness. Based on Dorothy’s case study, it can be stated that Dorothy has mania because her husband mentioned all these symptoms about her.
Bipolar disorder (BD) is extensively believed to be an outcome of a chemical imbalance in brain. Generally, BD appears due to several imbalances in neurotransmitters, genetic factors or environmental factors such as mental stress (Ayanoet al. 2020). According to WHO around 45 million people worldwide are affected by BD which consist of both depressive episodes and manic (Who, 2019).Some causes of BD are elaborated below.
Chemical imbalance within brain
First case of bipolar disorder can be chemical imbalances within brain. Chemicals are responsible for controlling functions of brain that are known as neurotransmitters, including dopamine, serotonin, and noradrenalin. The article of Perrotta (2019) revealed that, if there is any imbalance within the level of one or more than one neurotransmitter, an individual can develop some symptoms of this disorder, such as depression and mania. Carvalho, Firth &Vieta (2020) explained that people could experience episodes of mania when their noradrenalin levels are very high. Similarly, they can experience episodes of depression when levels of noradrenalin become very low. According to the case study, Dorothy behaved strangely in her first job filling classrooms with several plants, which looked like Amazon jungle. This behaviour continued and became a regular pattern. Her bizarre behaviour continued for more than a week. After having several episodes of this type of behaviour, she started to feel low and lethargic, which resulted in absence in the workplace.
However, between these episodes, she managed to hide her strange behaviour from colleagues; however, she started to increase concern about her future career due to her strange behaviour. In the case of bipolar disorder, cognitive theory can also be used. This theory has described that when people feel depressed, they become negative and change their perceptions about their future and world. In this context, Mandla, Billings & Moncrieff (2017) explained that bipolar disorder might be caused by the abnormal chemistry of serotonin in the brain. It is a neurotransmitter within the brain, and it is directly associated with the mood of an individual. It has been believed that abnormal serotonin levels can cause mood swings due to their feedback impact upon different brain chemicals (Calabròet al. 2018). This is unlikely; however, serotonin is not the only neurotransmitter involved in bipolar disorders, as some other neurotransmitters also play a major role in bipolar disorder. Because of the strange behaviour, it can be stated that it may be Dorothy’s condition caused by a chemical imbalance within her brain.
Besides chemical imbalance within the brain, it has been believed that the selected disorder is associated with genetics because it seems to run within families. Family members of any individual with this disorder have a high risk of developing this disorder themselves (Nhs.uk, 2021). O'Connell & Coombes (2021) explained that a family history of bipolar disorder is a crucial clinical prediction about onset of mood disorder within a patient. Depression and schizophrenia have the strongest genetic connection with bipolar disorder. In this context, Rowland &Marwaha (2018) explained that genetic factors regarding bipolar disorder are partly probable because of various single nucleotide polymorphisms that are highly prevalent in the general population. This scholar also elaborated that BD is often inherited with genetic factors that account for around 80% of cause of condition. For example, if one parent has BD, the child has a 10% chance of developing an illness. If both parents have BD, then their child has a 40% probability of developing illness. Although this is an inherited disorder, other family members do not need to develop this issue. However, in the case of Dorothy, she did not have any family members with BD; thus, genetic factors are not associated with her condition.
Stressful situations can frequently trigger bipolar disorder symptoms. Some examples of these triggers are as follows.
These kinds of life-changing events are responsible for depression episodes at any time of an individual. Besides these life events, BD can be triggered by sleep disturbances, physical illnesses, and overwhelming problems within everyday lives, including workplace and relationships (Lewis et al. 2018). In the case of Dorothy, a case study shows that her relationship with her son was not that good, and her son complained that his mother did not care about her. His son David is confused with her mother's bizarre behaviour as one minute full of energy and another minute she is opposite. Her son believes that Dorothy does this behaviour purposely; however, she stated this is not the case. During this period, she feels low and does not want to engage herself in any activities. Recently, David noticed his mother cut her arm during low mood. Thus, it can be stated that Dorothy’s symptoms affect the relationship with her son, which again adversely triggers her bipolar disorder symptoms.
In this context, BAS (Behavioural Activation hypothesis) can be used to discuss her condition. Perrotta (2019); Katz et al. (2021) explained that goal-attainment life events could trigger behavioural activation, increasing manic symptoms. Simultaneously, negative life events play a huge role in depressive symptoms against hypomania symptoms. Thus, it can be discussed that Dorothy's mental health condition is triggered by her workplace and her relationship with her son. In the workplace, she tried to put ideas on their colleagues, and when one of their colleagues did not allow her to do so, she felt bad. Therefore, all these reasons contribute to increased symptoms of bipolar disorder, and if she gets early intervention, her condition may improve effectively.
According to Vietaet al. (2018), although the disease has genetic histories to be the major cause, several other factors, such as environmental, significant life events, are responsible for developing this multifactorial disease. This is identified as environmental risk factor theory of bipolar disease, and it suggests that life events identified as stressors are responsible for future events of bipolar disease phases. However, results gathered based on this theory are not very reliable, as a few studies have found a definitive link between identified life events and mood disorders. On the contrary, other studies found that stressful life events are not linked with mood swings events in patients (Perrotta, 2019). However, life events associated with severe illness, lifelong sexual abuse are major causes in worse cases of bipolar disorder.
In order to initiate treatment of Dorothy, professionals can proceed with clinical synonymic diagnostic tests based upon examination of mental health status and history and excluding laboratory diagnostic tests. Based on Dorothy's detailed histories of childhood, education, relationships, and details of her disorder episodes, assessment of etiological factors are essential. It includes the following assessment of tests: vitamin D, folate, blood alcohol, B12, urinalysis, urine toxicology, levels of TSH (Thyroid Stimulating Hormone), and liver function tests (Lee & Swartz, (2021). Along with the test results and detailed analysis of mental status and histories of Dorothy, filling up screening questionnaires such as Mood Disorder Questionnaire can be helpful for diagnosis.
The basis of treating Bipolar disorder is associated with consecutive applications of psychotherapy and medications. As per Lee & Swartz (2021), process of treating this disorder consists of three distinct steps, those are:
Treatment of Dorothy's acute mania phases focused on safety, diagnosis, support, pharmacological treatment, education about disease and providing constant support. Major focus of pharmacological treatment, in this case, would be on mood stabilizers that will effectively suppress her erratic phases. According to Ahn et al. (2017), the treatment of this acute mania phase will last from six to 12 weeks, where major focus of psychotherapy provided to the patient focuses on dedicated support towards patient along with educating her about relevant topics. Psychotherapy is considered as a vital part of treatment for BD and it can be provided to patients individually, within a group or with family. Therapy sessions in this treatment method include cognitive behavioural therapy (CBT), family-focused therapy, psycho-education and interpersonal and social rhythm therapy (IPSRT).
These therapy sessions focus on replacing unhealthy, negative behaviours and beliefs with positive and healthy ones. Demissie et al. (2018) mentioned that CBT is beneficial in identifying what triggers the bipolar episodes of patients. Furthermore, this helps individuals to grasp strategies that are effective to deal with stresses and upsetting situations.
The main focus of this therapy is to stabilize daily rhythms like mealtimes, walking or sleeping. A consistent routine for eating, sleeping, exercising by following this therapy can work on mood management of people suffering from BD (Goldstein et al. 2018).
Besides that, communication with family members, recognition from loved ones can help in reducing warning signs from mood swings. NICE (National Institute for Health and Care Excellence) guidelines for bipolar disorder also stated that individual psycho-education is beneficial for treating mania and depression in patients with bipolar disorder (Nice.org.uk, 2020). This education helps the loved ones of the individuals suffering from BD to understand their situation, provide accurate support and make effective plans to mitigate it.
The next stage of treatment is about improvement, where mood symptoms of patients have to be improved. However, during this treatment phase, the patient is still going to be vulnerable towards mood instability. The prolonged treatment period lasts for about six months, and it pays attention to the psychotherapy shift towards identification of triggering factors that are called stressors. In the case of Dorothy, triggers can be poor relationships with family members, especially sons and bad relationships with colleagues. According to Sportiche et al. (2017), these factors or stressors cause mood instability, and these are associated with damaging work, relationships, or finances of the patient. After successful recovery at this point of treatment, i.e. not relapsing of acute mania phases, the patient then moves into the treatment procedure's final stage, which is the maintenance stage.
Major objective of this final stage of treatment focuses on preventing events of mania or depressive phases in future. Initiation of maintenance treatment indicated after first event of mania period in the patient due to the remitting and relapsing tendency of this disease. According to Hunt et al. (2016), in this phase of treatment, the major idea behind the treatment is associated with lifestyle changes, psychotherapy, and medications that will go for a long period, which will be of three types, (1) mood stabilizers, (2) antidepressant, and (3) antipsychotics. Application of psychotherapy in this phase stresses medication adherence, significant changes in lifestyle practices, education, and identification of potentially impactful effects from this disease, which may again lead to relapse. About monitoring for mania episodes, it is effective to maintain a mood chart or journal.
Maintaining a healthy lifestyle also works on mitigating BD. For example, eating snacks or meals in setting times within a day, increasing lean proteins, vegetables in diet, getting at least eight to nine hours sleep every night and waking up at the same time everyday help in reducing mood swings and depressive thoughts (Sylvia et al. 2019). In Dorothy’s case as she experienced difficulties in maintaining accurate sleeping, therefore, starting a healthy lifestyle can help to improve her situation. Besides that, it has been observed that being in isolation increases the sense of depression and bipolar disorders. It can be maintained by getting involved in social activities, spending time with friends and families and having support from loved ones also works on building confidence and reducing stress. It has been found in the case study that issues related with the teaching career of Dorothy’s also become an important factor that contribute to her mood swings.
BD is a disabling psychiatric disorder, and several people with BD experience significant difficulty to find appropriate treatment for preventing relapses of their condition. There are many complexities with BD treatment, and the severity of this illness increases with different types of episodes. Due to the cyclical nature of this illness and death, morbidity and disability connected to severe episodes of mania, sometimes professionals consider aggressive treatment as they can consider hospitalization. In case of handling Dorothy for her treatment, relevant ethical considerations are needed, and these are discussed below.
The first ethical principle that needs to be considered while working with this individual is beneficence. It refers to the duty of helping others frequently by removing and preventing potential harm. The case study shows that Dorothy had harmed herself as she had several cut marks on her arm when she had low moods. That means her bipolar disorder leads to self-harm tendencies. According to NHS UK, healthcare professionals need to develop trust levels with patients by supporting decision-making processes (Nhsproviders.org, 2021). Since Dorothy has developed a self-harm tendency, thus, beneficence ethical principle needs to be considered for preventing her from potential self-harm.
Varkey (2021) mentioned that requirements of informed consent regarding any treatment procedure include that patients have to be competent to decide and understand, receive full disclosure, act voluntarily and consent towards proposed action. According to the NHS, consent of treatment is essential before any intervention. In other words, consent to treatment defines an individual as having to have permission prior to receiving any medical treatment or test (Nhs.UK, 2021). That means, before giving any treatment to Dorothy, healthcare professionals need to take consent from her by giving a detailed explanation about the intervention procedure so that they can build trust with Dorothy.
Out of these four ethical principles, autonomy is contemplated as most central. It indicates freedom from any kind of external constraint as well as the presence of clinical psychological capacities, including voluntary decision-making, intending, and understanding capacity (Ratheeshet al. 2016). In this case, healthcare professionals need to give freedom to Dorothy so that she can be a part of the decision-making process.
Truth telling is the crucial component in the patient-physician relationship, and absence of this component, physicians would not be able to build trustful relationships with patients (Nice.org.uk, 2020). Patients have the right to know about their prognosis and diagnosis. Thus, in case of Dorothy, physicians need to inform her about her condition and the selected intervention so that she can trust her physicians and consider the selected interventions.
This report has aimed to discuss the provided case study and find out the issue of the individual in the case study. It has identified the case study and explained it with the help of DSM-5 criteria. From that information, it can be concluded that the patient suffered from bipolar disorder and required effective intervention to improve her condition. Based on her condition, it has been concluded that psychotherapy will be beneficial for her. Before treating her, physicians need to consider some ethics such as beneficence, informed consent, and truth telling.
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