Joker's bipolar I disorder treatment


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  • Just to give you guys an idea of how destructiv ethe k=joker is let me show you who harley used to be
  • Llet me show u a littl epic of jokers history with everyone
  • Pic of family
  • Joker as asked me to advertise his stand up comedy for him so here is a copy of the ticket
  • Joker's bipolar I disorder treatment

    1. 2. Joker's Bipolar I Disorder Treatment: Family Focused Therapy Philo Lomba Iona College
    2. 3. Diagnostic Assessment
    3. 4. Presenting problem/reason for referral <ul><li>My patient, Jack Napier, is a 59-year-old, white, widower, referred to as the Joker, was referred to me 2 July 2009. He is a master criminal with a clown-like appearance and has an unhealthily obsession with his nemesis Batman. Napier is referred for antisocial, bipolar, and bizarre behavior by his ex-girlfriend Harley Quinn. She is a former psychiatrist, known as Harleen Quinzel, seduced by the Joker. The Joker is known for constantly trying to kill her because he claims having &quot;feeling&quot; for her that are beginning to be too strong for him to handle. (Informant: quotations are from the patient, unless specified to the contrary.) </li></ul>
    4. 5. Chief complaint <ul><li>“ (patient is making allusion to the symptoms of bipolar disorder and his manic episodes) The fast ideas become too fast and there are far too many...overwhelming confusion replaces stop keeping up with it--memory goes. Infectious humor ceases to amuse. Your friends become are irritable, angry, frightened, uncontrollable, and trapped. Then, the very next day I wake up and I am on top of the world and Batman is never going to take that away from me again!!!” </li></ul>
    5. 7. History of Present Illness <ul><li>One day late at night, the Joker snuck inside Harley Quinn apartment in the middle of the night, appearing elated, agitated, perspiring and pale. He then launched into a rambling story about how after a week of sleepless nights and clever scheming, he had finally managed to come up with the perfect plan to defeat Batman. He continued to expressed his racing thoughts and ideas about his plan through excessive talking and pressured speech. </li></ul><ul><li>After 4 hours of standing, sitting and pacing while giving a grandiosity speech about himself, the joker’s excitable speech slowed down and he proceeded to seducing Harley Quinn to have sex with him. Something Harley Quinn pointed out he rarely did in his sane moods. Then, he slept for two hours and awoke with a blank stare. He was very irritable and became furious with Harley Quinn, blaming her for having wasted his precious time (time he insisted could have gone to perfecting his scheme against Batman). </li></ul><ul><li>The next day, Harley Quinn went to visit the Joker but he would not let her come inside his apartment. Instead, he kept rambling on about how no one was safe from Batman and that he couldn’t trust anyone to enter his apartment. While still outside the door, Harley Quinn noted that Joker had that same rushed speech as the night before and clear evidence of distractibility at every sound (phone ring, barking dog, etc). </li></ul><ul><li>Later that day Harley Quinn was approached by Batman, who claimed that for the previous 7 days, the Joker has been harassing him by standing outside his house all night, following him all day and sending him threatening notes. Batman was contemplating reinstating the Joker into an asylum but Harley Quinn convinced him not to by reassuring him that she would make sure it wouldn’t happen again. </li></ul><ul><li>The Joker’s posse (John, Jim and Joe), told Harley Quinn that around last 2 months, Joker started locking himself in his room all day feverously writing and thinking of ways to defeat Batman without any sleep or food. He would let no one into his room and late at night he would sneak out to spy on Batman, They insisted that the Joker was not taking any drugs or alcohols during these encounters and that his behavior was not due to any medical condition. </li></ul><ul><li>Harley Quinn believes that the Joker has been suffering from this conditioned for years but only recently has it come to her attention because of his last visit to her house. Although the joker denies his condition, being concerned about his worsening state, Harley Quinn, in collusion with Batman and the Joker’s posse (Jim, John and Joe) tricked the patient into leaving his room and being admitted into a psychiatric ward in Gotham City. </li></ul>
    6. 8. Past History- Developmental, Psychiatric, Drug and Alcohol and Family <ul><li>The patient was apparently well until June 1940, when to support his family, he, Jack Napier, gave up stand-up comedian to became a criminal. Napier broke into the plant where he was formerly employed as a chemical engineer. During the planning, the police contacted and informed him that his pregnant wife died in a household accident. Jack Napier immediately tried to get out of the deal but fails. The Batman shows up to stop him. They get into a fight which ended with Napier falling into a vat of chemical waste. He emerges with bleached white skin, red lips, green hair, and a permanent grin. According to Harley Quinn, these events drove the engineer completely insane, resulting in the birth of the Joker. </li></ul><ul><li>Little is known about the patient’s early childhood and family; however, the patient once recounted a tale of an abusive father and runaway mother to his ex-girlfriend Harley Quinn. </li></ul><ul><li>Throughout the past 40 years, Napier used the alias of the Joker, became a homicidal manic and a goofy trickster-thief. </li></ul><ul><li>The patient was first admitted into psychiatric ward by the Batman for treatment of insanity after going on a killing spree for a whole week without sleep. However, his then therapist Harley Quinn, fell madly in love with the joker and helped him escape. Blinded by her love for him, she was unable to truly diagnose the patient with the earlier signs of bipolar disorder. Later on after leaving her profession and siding with the joker has his side kick, she finally became aware of the Joker’s destructive pattern; </li></ul><ul><li>Harley Quinn suspects that he is suffering from bipolar disorder. On occasionally, she claims the patient is very unpredictable, one day he is extremely irritable and distractible, the next he has excessive &quot;high&quot; or euphoric feelings. There are even sustained periods of unusual, even bizarre, behavior with significant risk-taking that occur 4 times a year and last several weeks but no more than 2-3 months. During those periods, the Joker behaves in a provocative or obnoxious behavior and develops increased energy, sex drive, rapid talking and thinking. Harley Queen also states that she has observed increased levels of agitation and poor judgment coupled with decreased sleep. Harley Quinn admits to having tried to talk to the patient about this but he is in complete denial of his problem. </li></ul>
    7. 10. Mental Status Examination
    8. 11. Mental Status Examination <ul><li>[Mini-MSE test was present but formal testing was not performed because the patient was not co-operative and thought testing was tedious and insulting to his intelligence] </li></ul><ul><li>Appearance: the patient is a Caucasian male with the apparent age of 80 even though he is 59. He is observed to be malnourished and has dilated pupils. His bleached white skin, red lips, green hair, and a permanent yellow grin made him look like a doll. Patient’s attire looks as if it has been put on in haste and is disorganized. His clothes are too bright, colorful and frequently attract attention. </li></ul><ul><li>Behavior: The patient makes a lot of eye contact. His constant pacing around the room, restless, hypervigilant and hyperactive causes him to perspire. He experiences akisthesia and appears uncomfortable if kept still. The patient is openly combative and aggressive. He has no patience or tolerance for others. He can be highly demanding, violently assertive, and highly irritable. </li></ul><ul><li>Speech: the patient speaks loquaciously, fluently, loudly and at a very fast pace. He spontaneously starts a pressured speech as soon as he enters the room. Although his speech is articulate, he repetitively mentions Batman. </li></ul><ul><li>Thought content: The patient is excessively self-confident and/or grandiose. He also acted out of the grandiose belief that others (specifically therapist) must obey their commands, wishes, and directives. The patient has preoccupations of delusional content about Batman and has paranoid beliefs that Batman is working against him secretly and conspiratorially. He uses homicidal ideation as a way to defends him selves against others. </li></ul><ul><li>Thought process: Patient’s thoughts are goal-directed, logical and coherent with tight associations. The patient has frequent flight of ideas about plans on how to defeat Batman. </li></ul><ul><li>Affect/mood: The patient’s mood is concordant with what he is saying and doing and is expressed in full range of emotions during exam. The patient is euphoric and demonstrates annoyance and irritability whenever he is not in control of the therapy session. </li></ul><ul><li>Orientation/Perceptions: The patient knows the time and location, and he recognizes people </li></ul><ul><li>Cognition/attention/memory: The patient remembers immediate, recent, and distant events. He’s ability to recall information can be extremely vivid and expanded but he experiences difficulty in concentrating and focusing. </li></ul><ul><li>Judgment/insight: The patient is over-involved in work. During session, patient did not listen to any feedback, suggestions, or advice from friends, family, or colleagues. The patient has no insight into the extreme nature of his demands, plans, and behavior. </li></ul>
    9. 12. DSM-IV Diagnosis
    10. 13. DSM-IV Diagnosis <ul><li>Axis I: 307.50 Eating disorder not otherwise specified (EDNOS) (provisional) </li></ul><ul><li>780.52 Insomnia type (provisional) </li></ul><ul><li>309.81 Posttraumatic stress disorder (provisional) </li></ul><ul><li>296.44 Bipolar disorder I, most recent episode manic severe with psychotic features </li></ul><ul><li>298.9 Psychotic Disorder NOS (provisional) </li></ul><ul><li>Axis II: 301.0 Paranoid personality disorder (provisional) </li></ul><ul><li>301.7 Antisocial personality disorder (provisional) </li></ul><ul><li>301.81 Narcissistic personality disorder (provisional) </li></ul><ul><li>Axis III: None </li></ul><ul><li>Axis IV: Death of pregnant wife, falling in acid and unemployment. </li></ul><ul><li>Axis V: Global Assessment of Functioning (GAF) </li></ul><ul><li>Current: GAF 18; some danger of hurting self or others OR occasionally fails to maintain minimal personal hygiene OR gross impairment in communication. </li></ul><ul><li>Highest in past year: GAF 70; some mild symptoms OR some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships. </li></ul>
    11. 14. Biopsychosocial Formulation
    12. 15. Biopsychosocial Formulation <ul><li>Bipolar disorder, especially bipolar I, has a major genetic component; however, because we lack information, a family history of mood disorder is impossible to make; however, the patient’s manic episodes produces grandiose and overvalued ideas and agitation. The onset of the Joker’s manic phase is not yet known but his past insinuates a post-traumatic event that may have caused the onset of the bipolar disorder. Since, according to the patient’s posse, his periods of enormous energy, is not related to substance abuse, according to the DSM-IV-TR, the patient meets the criteria for bipolar disorder. </li></ul><ul><li>Psychodynamically, the manifestation of the losses, ie, the loss of self-esteem and the sense of worthlessness, caused by the death of his pregnant wife and identity caused him to have great anxiety within him which resulted in the manifestation of mania. Therefore, that mania serves as a defense against the feelings of depression. Also, the mood disorder coupled with the manic episodes lasting over a week suggest Bipolar disorder I, most recent episode manic severe with psychotic features. The diagnosis of bipolar disorder is firm. </li></ul><ul><li>An antisocial personality disorder is a distinct possibility since the patient has showed history of not engaging well in society. </li></ul><ul><li>In addition, the patient inability to have close relationships (as is apparent with Harley Quinn) and his inappropriateness of being suspicious of everyone around him and the variability of his overvalued ideas supports a diagnosis of paranoid personality disorder. In light of current information, the patient’s symptoms strongly suggest paranoid personality disorder, even though they frequently meet short of the DSM-IV-TR criteria. </li></ul><ul><li>In view of his longstanding meticulousness, perfectionism, excessive rate of self admiration and adoration at the expense of others, a Narcissistic personality disorder should be considered. </li></ul>
    13. 16. Treatment Plan
    14. 17. Treatment Plan <ul><li>The combination of pharmacotherapy with the promising method of Family Focused Therapy (FFT) will be the protocol used for the treatment of Bipolar Disorder I, most recent episode manic severe with psychotic features. Family is a term that can have different meaning depending on culture and beliefs. Throughout this paper, the word &quot;family&quot; is used in term of family structure or individuals in patient's life that significantly influences patient life as well as treatment success and development. </li></ul><ul><li>The ultimate goal of this treatment is to allow the patient to gain control over his disorder by building skills that might prevent or decrease the impact of future episodes. The intermediate goal of the treatment is to strengthen the family structure so that the patient has supporting sources that will help keep his treatment effective. The immediate goal is to educate patient and his family about the disorder so that they can be better prepared to deal with the challenges of the disorder in a productive way. The idea is that when families understand the disorder, learn skills to minimize family conflict, and follow an illness-management program, the outcomes of the disorder will be improved (Sharf, R., 2008). </li></ul><ul><li>This treatment will thus consisting of first subscribing medications (lithium) to control the disorder. Then new skills are taught to the patient to reduce the chance of relapsing episode caused by the disorder: psychoeducation about illness-management strategies, communication enhancement training and problem solving skills. This will increase families’ abilities to help enhanced patients’ adherence to pharmacotherapy and reduced the number of relapses (Miklowitz D.J. et al, 2008). </li></ul>
    15. 18. Treatment Plan <ul><li>During the course of the treatment, the patient is given 20 mg of lithium for bipolar disorder and he is instructed to take once a day with a meal. </li></ul><ul><li>The next part of the treatment is composed of a total of 21 sessions over the course of 9 months. The first part of the treatment, which lasts 7 sessions, is psychoeducation. Patients and families are encouraged to learn about the disorder in terms of symptoms, nature, course and treatment. This prevents blame among family and builds an alliance in the family called “Collaborative care”. Collaborative care has been found to decrease patients’ hopelessness and enhance life functioning over time (e.g., Morris et al., 2007). </li></ul><ul><li>During this part of the treatment, the families are also taught Relapse Prevention Planning. Patients and families identify what caused the patient past relapse. Then the clinician familiarizes clients with signs of mania and depression (e.g. Deterioration of mood, sleep and appetite). The families and the patients are encouraged to develop a plan demonstrating concrete steps in case of relapse. </li></ul><ul><li>The second part of FFT, which lasts 7 to 10 sessions, involves Skills training in Communication enhancement training (CET). Using behavioral modeling and rehearsal patients learn to clearly communicate feelings, listening strategies, and making positive requests for change in others. Families are asked to practice these skills between sessions. These techniques are directed at reducing levels of high EE and negative relative/patient interactional behaviors that can lead to relapse. </li></ul><ul><li>The last part of the treatment, which lasts 4 to 5 sessions, involves acquiring problem solving skills. Families and patients are first asked to define a problem. Then, they brainstorm about solutions to the problem and finally pick a specific solution as a team. Later, families and patients are asked to implement plan for the solution and finally the initial state of the original problem is reviewed. In Family Focused Therapy, clinicians are always encouraged to start with problem topics that are less emotionally charged to ensure success the first time. </li></ul><ul><li>At the end of all 21 sessions, termination and review of goals are established. If patients are still unstable or if family is still having difficulties, booster sessions are implemented and increase in dosage might also be recommended. Some treatment sessions include strategies to put parents back in charge of their teen’s healthy development (Sharf, R., 2008). </li></ul>
    16. 19. Therapy Session <ul><li>This is an excerpt of a session of Family Focused Therapy, during the last part of the treatment, involving acquiring problem solving skills. </li></ul><ul><li>&quot;The family (Harley Quinn, Joker, Joker's posse and Batman) decided to tackle the patient's stalking habits; they are trying as a team to come up with different solution to this problem: (This is the first session of this part of the therapy) </li></ul><ul><li>-Harley Quinn: Perhaps you should occupy yourself with more important things love. Why don't you consider getting a hobby? Perhaps we can learn pottery together and then maybe catch a movie together. </li></ul><ul><li>-Batman: Well that a good idea! You used to be a comedian, why don't you do standup comedy again? A friend of mine actually has a bar and every night is open mic, I could get you a gig? What do you say? </li></ul><ul><li>-Joker: Are you mocking me? You know full well why I won't do stand-up comedy. </li></ul><ul><li>-Joker's posse: Yeah are you mocking the boss? </li></ul><ul><li>-Therapist: Well now, let's all settle down. Mr. Napier... </li></ul><ul><li>-Joker: My name is Joker! </li></ul><ul><li>-Joker's posse: Yeah, the boss is right! </li></ul><ul><li>-Therapist: Alright then, Joker, why do you think Batman is mocking you? </li></ul><ul><li>-Joker: because he is knows about my past and he knows why is stopped doing that. He is just trying to torture me by reminding me of my past. He wants me to suffer that tragedy over and over and over again. Well I WON'T and I WON'T let him win. I'll find a way to show him just who is cleverer and I'll repay him TEN times over!!! </li></ul><ul><li>-Joker's posse: Batman is whatever boss says. </li></ul><ul><li>-Batman: Not again! You see what I mean Mrs. Lomba (therapist) he is determined to blame me for everything in his life. He refuses to take responsibility for ANYTHING. </li></ul><ul><li>-Harley Quinn: Well you are responsible for a lot of bad things in his life. So... </li></ul><ul><li>-Therapist: All right guys let get it together. The purpose of this exercise is not to blame anyone for anything. It is to acknowledge the problem and then regardless of where it comes from and why find a solution for the problem and implement it. So let's try this again... </li></ul>
    17. 20. Therapy Session <ul><li>(This is the third session of this part of the therapy) </li></ul><ul><li>-Joker: You know Harley babe, you were right, I do love standup comedy. I missed the whole experience; the stage, lights, not having to force a laugh out of people </li></ul><ul><li>-Joker's posse: Boss you are so funny! (hahaha) </li></ul><ul><li>-Harley Quinn: Suga' bear, I knew you would. and i love copying to your gig every night and seeing standing on that stage looking so manly. It just brings me back to those days... </li></ul><ul><li>-Batman: Do I REALLY need to be here? I mean clearly any suggestions I make is disregarded and all the credit for my hard work is always attributed to someone else. </li></ul><ul><li>-Harley Quinn: oh hush up! We are not here (therapy session) for you narcissistic personality disorder. This is about my baby so stop your complaining! </li></ul><ul><li>-Therapist: let me ask you a question Batman, has Joker been stalking you lately? </li></ul><ul><li>-Batman: No not at all. Actually I think I am the one stalking me now because I am addicted to his stand-up comedy. </li></ul><ul><li>-Therapist: Once again guys it's not about who did what or why. It about how we get rid of it. </li></ul><ul><li>-Joker: I completely agree so when are we going to start working a getting rid of Batman because as am sure you can see, he has become a real nuisance to our therapy sessions. &quot; </li></ul>
    18. 22. Literature Review of treatment for disorder
    19. 23. Literature Review of Family Focused Therapy <ul><li>Bipolar Disorder is major depressive episodes with at least one hypermanic or manic episode. </li></ul><ul><li>- Prevelance of 1% , 15% of which accounts for 60% of all suicides in the US (Maxmen, J. & Ward, N., 2009). </li></ul><ul><li>- prevention of relapse is vital. </li></ul><ul><li>Pharmacotherapy (etc Lithium) widely used for treatment, prevention and symptom control of bipolar disorder but they are not completely effeective; </li></ul><ul><li>Study shows that 55 to 70% of patients have relapses within a 2 to 4 year period even when maintained on pharmacotherapy (Geller, B., Tillman, R., Craney, L. & Bolhofner, K., 2004). </li></ul><ul><li>because: </li></ul><ul><li>- bipolar patients are highly prone to medication nonadherence and relapse frequently occurs following the sudden discontinuation of medications. </li></ul><ul><li>- not treating the psychosocial aspects of bipolar disorder which are major contributors to relapses during treatments. </li></ul>
    20. 24. Literature Review of Family Focused Therapy <ul><li>Miklowitz D.J. et al (2008) showed success of treatment of mood disorders, specifically Bipolar Disorder, is related to the patient’s family “Expressed Emotion” (EE). EE is operationally defined as a measure of the emotional attitudes of caregivers/relatives toward a family member with a psychiatric disorder” (Butzlaff, R.L., Hooley, J.M., 1998). In general, patients with high-expressed emotion families tend to relapse. Treatment of bipolar disorder with FFT was been shown to reduce levels of EE (Miklowitz D.J. et al, 2008) </li></ul><ul><li>Miklowitz, D., George, E., Richards, J., Simoneau, T. & Suddath, R. (2003) 101 patients assigned to Family Focused Therapy and medication or a crisis management intervention with medication. Findings indicated that if patients were in Family Focused Therapy and medication they had fewer relapses, longer periods of wellness and less severe depressive and manic symptoms (Miklowitz, D. et al, 2003).  </li></ul><ul><li>Dr. Miklowitz et al. (2008), FFT was proven to also work on adolescents. 58 were randomly assigned to FFT plus medication or three sessions of family psychoeducation, with crisis intervention as needed. Results showed that adolescents in the FFT group recovered from their depression faster and stabilized four weeks sooner than those in the enhanced care group. </li></ul><ul><li>  Pavuluri, M.N. et al (2004) combined FFT with (Cognitive Behavioral Therapy) CBT and pharmacotherapy for 34 school-aged children and adolescents with bipolar disorder. Results showed significant reductions in the severity of bipolar symptoms and increased functioning. </li></ul><ul><li>  The results of these studies are consistent in suggesting that FFT is an efficacious adjunct to pharmacotherapy for patients of various ages (children, adolescents and adults) with bipolar disorder.    </li></ul><ul><li>Family Focused Therapy treatment allows patients to gain control over their disorder by building skills that might prevent or decrease the impact of future episodes. The combination of FFT with other promising methods such CBT may prove to be a strong match for specific populations of patients identified by age of onset, symptom severity or family structure. </li></ul>
    21. 25. References <ul><li>Butzlaff, R.L. & Hooley, J.M. (1998). Expressed Emotion and Psychiatric Relapse: A Meta- </li></ul><ul><li>       analysis. Archives of General Psychiatry, 55 (6), 547-552. </li></ul><ul><li>Geller, B., Tillman, R., Craney, L. & Bolhofner, K. (2004). Four-Year Prospective Outcome   and Natural History of Mania in Children with a Prepubertal and Early Adolescent </li></ul><ul><li>       Bipolar Disorder Phenotype. Archives of General Psychiatry, 61 (5), 459-467. </li></ul><ul><li>Goodwin, F., Fireman, B., Simon, Hunkeler, G., Lee, E. & Revicki, J. (2003). Suicide Risk  in Bipolar Disorder During Treatment With Lithium and Divalproex. Journal of  American medical association, 290 , 1467-1473. </li></ul><ul><li>Maxmen, J. & Ward, N. (2009). Essential Psychopathology and Its Treatment (Third Edition), </li></ul><ul><li>       Mood Disorders (pp. 360-361). New York: Norton & Company. </li></ul><ul><li>Miklowitz, D., George, E., Richards, J., Simoneau, T. & Suddath, R. (2003). A Randomized </li></ul><ul><li>       Study of Family-Focused Psychoeducation and Pharmacotherapy in the Outpatient </li></ul><ul><li>       Management of Bipolar Disorder. Archives of General Psychiatry , 60 (9), 904-912. </li></ul><ul><li>Miklowitz, D.J., Axelson, D.A., Birmaher, B. et al.(2008)  Family-focused treatment for  adolescents with bipolar disorder: results of a 2-year randomized trial. Archives of </li></ul><ul><li>       General Psychiatry, 65 (9), 1053-1061. </li></ul><ul><li>Pavuluri, M.N., Graczyk, P.A., Henry, D.B., Carbray, J.A., Heidenreich, J. & Miklowitz, D.J. </li></ul><ul><li>       (2004). Child and Family Focused Cognitive-Behavioral Therapy for Pediatric Bipolar  Disorder: Development and Preliminary Results. Journal of American Academic Child  and Adolescent Psychiatry, 43 (5), 528-537. </li></ul><ul><li>Sharf, R. (2008). Theories of Psychotherapy and Counseling: Concepts and Cases (Fourth </li></ul><ul><li>       Edition), Family Therapy (pp. 478-519). Belmont, CA: Thomson Brooks/Cole. </li></ul>
    22. 26. Question/Comments?