1 bipolar disorder 8 Captain of the Ship: Bipolar Disorder The following case study details the treatment approach for a 35-year-old Caucasian male who presented to the clinic for help with his mood disorder. The assessment and intake supported the diagnosis of bipolar disorder, subtype II. The following analysis presents the details related to both pharmacology and psychotherapy, as well as information related to medical management, community support resources, and appropriate follow-up. Chief Complaint The client came to the clinic reporting that he “could no longer deal with his up-and-down mood swings and that he was at the end of his rope.” History of Presenting Problem This client stated that he has had mood swings for as long as he could remember, and that right now he was in the “up” phase of this alternating mood pendulum. From an inspection of the genogram that the client provided, there was a noticeable inheritance pattern of the bipolar. Notably, this client had evidence of bipolar on both maternal and paternal sides of his genogram. Research has shown that bipolar has a high heritability rate. Kern (2014) reported on the concordance rates of twins with bipolar, stating the rate was from 60-80%. In other studies, the heritability of bipolar is demonstrated albeit at lower rates (Maier et al. (2005). The DSM-V characterizes bipolar II disorder as one in which individuals experience a period of at least 4 days of hypomanic symptoms; once this criterion is met, the person fits the diagnosis of bipolar II regardless of the duration of future hypomanic episodes (APA, 2013). Additional symptoms to support this diagnosis were the client’s admission that he was taking on several projects and tasks at work simultaneously; sleeping little; experiencing racing thoughts; and feeling invincible. The intake showed the client’s extremely fast talking, switching subjects haphazardly, and admission of both depressive and hypomanic episodes, all of which point to a diagnosis of bipolar II (296.89 F31.81) (APA, 2013). Current Medications This client denied taking any medications, either over the counter or from a doctor. Although he claimed he was in good health, he did report that he frequently got headaches but not of migraine proportions. He described them as more of an annoyance than a health problem. He gained relief from either Motrin or Tylenol during these headache episodes. He denied taking any vitamins or herbs or any other OTC substances. Relevant History The client reported that his mood swings began when he was in his early 20s. As he witnessed other family members suffering from these mood swings, he came to believe they were normal. The client appeared to be in good health, was not overweight, and appeared to take good care of himself. He was dressed well and was oriented x4. He stated that he earned a good living working as a financial consultant, enjoyed his work, but could not deal with the revolving mood swings anymore. His pu ...

1. 1
bipolar disorder 8
Captain of the Ship: Bipolar Disorder
The following case study details the treatment approach for a
35-year-old Caucasian male who presented to the clinic for help
with his mood disorder. The assessment and intake supported
the diagnosis of bipolar disorder, subtype II. The following
analysis presents the details related to both pharmacology and
psychotherapy, as well as information related to medical
management, community support resources, and appropriate
follow-up.
Chief Complaint
The client came to the clinic reporting that he “could no longer
deal with his up-and-down mood swings and that he was at the
end of his rope.”
History of Presenting Problem
This client stated that he has had mood swings for as long as he
could remember, and that right now he was in the “up” phase of
this alternating mood pendulum. From an inspection of the
genogram that the client provided, there was a noticeable
inheritance pattern of the bipolar. Notably, this client had
evidence of bipolar on both maternal and paternal sides of his
genogram. Research has shown that bipolar has a high
heritability rate. Kern (2014) reported on the concordance rates
of twins with bipolar, stating the rate was from 60-80%. In
other studies, the heritability of bipolar is demonstrated albeit
at lower rates (Maier et al. (2005).
The DSM-V characterizes bipolar II disorder as one in which
individuals experience a period of at least 4 days of hypomanic
symptoms; once this criterion is met, the person fits the
diagnosis of bipolar II regardless of the duration of future
hypomanic episodes (APA, 2013). Additional symptoms to
support this diagnosis were the client’s admission that he was
taking on several projects and tasks at work simultaneously;

2. sleeping little; experiencing racing thoughts; and feeling
invincible. The intake showed the client’s extremely fast
talking, switching subjects haphazardly, and admission of both
depressive and hypomanic episodes, all of which point to a
diagnosis of bipolar II (296.89 F31.81) (APA, 2013).
Current Medications
This client denied taking any medications, either over the
counter or from a doctor. Although he claimed he was in good
health, he did report that he frequently got headaches but not of
migraine proportions. He described them as more of an
annoyance than a health problem. He gained relief from either
Motrin or Tylenol during these headache episodes. He denied
taking any vitamins or herbs or any other OTC substances.
Relevant History
The client reported that his mood swings began when he was in
his early 20s. As he witnessed other family members suffering
from these mood swings, he came to believe they were normal.
The client appeared to be in good health, was not overweight,
and appeared to take good care of himself. He was dressed well
and was oriented x4. He stated that he earned a good livi ng
working as a financial consultant, enjoyed his work, but could
not deal with the revolving mood swings anymore. His purpose
for coming to the clinic was get help for this apparent mood
disorder.
Diagnostic Impression
As stated, the client’s symptomatology and relevant history
align with a diagnosis of bipolar disorder, subtype II. Running
along a continuum from mild to severe, this disorder is saliently
circumscribed by the major depressive phase alternating with
the hypomanic phase (Antokhin et al., 2010; APA, 2013). The
DSM-V clearly states that the bipolar II diagnosis is confirmed
by individuals’ experience with at least one episode of major
depression and at least one hypomanic episode (APA, 2013;
Samalin et al., 2016). Because the client has never experienced
a full-blown mania, so typical of the bipolar I subtype, the
diagnosis is best supported by the criteria of the bipolar II

3. subtype.
Psychopharmacology and End Points
Both subtypes of bipolar can be extremely debilitating to
individuals who suffer from these illnesses. For one, this client
reported regular sleep disturbances and an omnivorous appetite
for increased responsibilities at work, the result of which could
be extreme overwhelm. Sadock et al. (2014) described such
overwhelm, stating that bipolar individuals often experienced
extreme emotional distress because of such unrelenting task
assumption. The typical treatment for bipolar patients and one
directed at mood stabilization is lithium therapy (Stahl, 2013).
The recommended regimen based on all the information for this
case would be 600mg of a lithium salt TID. Ward (2017)
reported on the efficacy of this treatment to target the up-and-
down nature of the disorder. During lithium therapy, clients
must have their blood monitored regularly to ensure that the
target of 1-1.5mEq/L blood serum levels is established (Sadock
et al., 2014). Supplemental pharmacology might include the
drugs venlafaxine and olanzapine, the first an antidepressant
and the second an antipsychotic (Stahl, 2013). These meds
would help with any psychotic episodes that the client might
experience (Sadock et al., 2014). To avoid overprescribing of
psychotropics, no adjutant therapy would commence until the
results of lithium therapy have been established. The
therapeutic endpoint would be improvement in the client’s mood
swings over the ensuing weeks after initiation of pharmacology.
Psychotherapy and End Points
The gold standard of psychotherapy is cognitive behavioral
therapy (CBT) and will be recommended on a weekly basis. The
literature is replete with research supporting the efficacy of
CBT in bipolar cases (Jones et al., 2012; Sadock et al., 2014).
Gabbard (2014) reported that bipolar patients who attended
regular CBT therapy enjoyed welcome relief from the nefarious
symptoms of the illness. But as with other mental health
disorders, bipolar is best treated with a multimodal approach.
Antokhin et al. (2010) discussed the benefits of sociotherapy to

4. complement modalities like CBT and other group behavioral
therapies. The endpoint of psychotherapy would be to restore
normal functioning to the client, as much as is realistically
possible, and see him begin to be less hampered by the disorder,
especially insofar as his sleep disturbance and feelings of
invincibility.
Medical Management and Follow-Up
Importantly, lithium therapy can be dangerous if blood
levels rise to 2.5mEq/L (Sadock et al., 2014). For this reason,
the client will be sent for regular blood draws to ensure levels
remain within the safe zone. Moreover, the client will be
enjoined to see his regular doctor for routine vaccinations and
other preventive routine diagnostic tests. The client will be
educated on the important side effects of pharmacology.
Notably, lithium can produce side effects of diarrhea, muscle
fatigue, and shaky gait (Stahl, 2013). The client will be advised
to notify his doctor immediately of any of these problems and to
report to the nearest hospital for emergency care.
Support Resources
The National Alliance on Mental Illness (NAMI) offers a
wide range of social support services through its website and
national hotline. These services encompass everything from a
suicide hotline to help finding a mental health specialist to
books and other printed materials on bipolar (NAMI, 2018).
Another online resource is the Depression and Bipolar Support
Alliance (DBSA), which offers abundant information on bipolar
and related mood disorders (DBSA, 2020). The FAIR START
program helps persons with bipolar to find expert clinical
research on the disorder (FAIRSTART, 2019). This program is
run by Stanford Medical School and offers help for bipolar
individuals to get evaluated properly and find appropriate
treatment.
References
American Psychiatric Association (APA). (2013). Diagnostic
and statistical manual of mental disorders (5th ed.). APA.

5. Antokhin, E., Bardyurkina, V., Budza, V., Kryukova, E., &
Baldina, O. (2010). Bipolar depression of the II type:
Psychopathology, therapy. European Psychiatry, 25.
Depression and Bipolar Support Alliance (DBSA). (2020).
https://www.dbsalliance.org/
FAIR START. (2019). From affective illness to recovery:
Student access to rapid treatment (FAIR START).
Stanford Medicine.
http://med.stanford.edu/bipolar/Fairstart.html
Gabbard, G. O. (2014). Gabbard’s treatment of psychiatric
disorders (5th ed.). American Psychiatric Publications.
Jones, S., Mulligan, L. D., Law, H., Dunn, G., Welford, M.,
Smith, G., & Morrison, A. P. (2012). A randomized
controlled trial of recovery focused CBT for individuals with
early bipolar disorder. BMC Psychiatry, 12: 204.
Kerner, B. (2014). Genetics of bipolar disorder. Applied
Clinical Genetics, 7: 33-42.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3966627/
Maier, W., Höfgen, B., Zobel, A., & Rietschel, M. (2005).
Genetic models of schizophrenia and bipolar disorder:
overlapping inheritance or discrete genotypes? European
Archives of Psychiatry and Clinical Neuroscience, 255(3),
159–166.
National Alliance on Mental Illness (NAMI). (2018). Retrieved
June 30, 2020 from https://www.nami.org/
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan &
Sadock’s synopsis of psychiatry: Behavioral sciences/clinical
psychiatry (11th ed.). Wolters Kluwer.
Samalin, L., de Chazeron, I., Vieta, E., Bellivier, F., & Llorca,
P. (2016). Residual symptoms and specific functional
impairments in euthymic patients with bipolar disorder. Bipolar
Disorders, 18(2), 164–173.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology:
Neuroscientific basis and practical applications (4th ed.).
Cambridge University Press.
Ward, I. (2017). Pharmacologic options for bipolar disorder.

6. Clinical Advisor, 20(3), 17–25.