300 words conceptualization
vwccspt12
DiagnosisPresentationSarahM.pptx
Bipolar I Disorder Case Presentation
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Client Demographic Information, Historical Background, and Presenting Problems
History: 45-year-old Caucasian female, divorced, mother of two children (14 and 17)
Good: Rented townhouse with children; On leave as an administrative assistant
Family hx: Depression in mother; Uncle bipolar; No family history of mania; No family history of substance abuse; No family history of suicide
Verbalized problems: Mood instability, racing thoughts, irritability, insomnia (2-3 hrs/night during mania)
Recent Manic Episode: 10 days, impulsive spending ($3,000+), unfinished projects
No current: Absent depressive symptoms, no feelings of guilt, no lack of motivation; Absent SI
Sarah M. is a 45-year-old divorced Caucasian woman who lives in a rented town house with her two children (14 and 17 years of age). She is an administrative assistant but is on leave because of mood instability. She was diagnosed with Bipolar I at age 29 after being hospitalized, and has had 1-2 manic episodes per year, mostly as a result of stress or disruptions of sleep. Her family have a history of mood disorders. Problems presenting include: Mood instability, racing thoughts, increased irritability, sleep problems. In her last 10-day episode she didn't sleep more than 2-3 hrs., spent more than $3000 on impulsive spending and tried to start several projects but was unable to finish them. Now she says she is embarrassed, tired, and has low motivation and guilt feelings. She has strengths of insight, motivation to her children, supportive sister and stable housing. This background guides the comprehensive assessment approach with a focus on safety, adherence and relapse prevention.
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Deductive Reasoning in Clinical Interviewing.
A method of diagnosis that begins with general symptoms and progresses to detailed diagnostic criteria (Regent et al., 2023).
Purpose: Evaluate the DSM-5-TR symptoms of Bipolar I, systematically.
Question 1: Have you ever been more excitable or angry than usual and had a lot more energy than normal?
Question 2: During times of increased energy, what have you noticed about your sleep and risky or impulsive behaviors?
Question 3: What are the impacts of all of these emotional shifts on your job, parenting, finances and/or relationships?
Question 4: What are the signs that you observe at the beginning of a manic episode?
Top-down clinical reasoning, referred to as "deductive reasoning," starts with the client's presenting complaints and then proceeds to the specific diagnostic criteria of the DSM-5-TR (Regent et al., 2023). For Sarah, it means posing hypotheses about manic and depressive symptoms to establish the diagnosis of Bipolar I Disorder. During the interview, I'd try to establish rapport and then ask these semi-structured questions: 1) To see if the person had elevated mood and energy (Criterion A for manic episode). To examine reduced sleep requirements, egocentricity and reckless behaviour (Criteria B). 3) To assess social/occupational impairment. 4) To recognize risk factors and signs of relapse. The questions give Sarah the opportunity to give specific examples and for me to observe any pressured speech or restlessness. This deductive process helps to make the correct diagnosis, rule out differential diagnoses (such as a substance induced mood disorder or ADHD), and guide treatment. There would be other probes added about adherence to medication and attitudes towards mental health.
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Client Diagnosis (DSM-5-TR Criteria)
The overall goal is to record the most current diagnosis. The overall objective is to document the most recent diagnosis.
Manic Episode Criterion A: Elevated/irritable mood + increased energy (for ≥1 week)
Met:10 days episode with racing thoughts and irritability and minimal sleep.
Additional Criteria (3+): Inflated self-esteem, distractibility, excessive involvement in risky activities (spending)
Loss: marked change in functioning and loss of income, and/or social relations (relationships) that does not allow for the ability to work or lead a normal life,
Note: This is the same as Z63.5 Disruption of family by separation or divorce (contributing factor).
In DSM-5-TR, Sarah exhibits all of the criteria for Bipolar I Disorder. One week of abnormally elevated, expansive or irritable mood (her 10-day episode) meets Criterion A for the manic episode. In this time, she experienced at least three of the symptoms listed in Criterion B (decreased need for sleep - 2-3 hours per night, racing thoughts (flight of ideas), and high-risk pleasurable activities with potential for painful consequences - impulsive spending on $3,000 worth of clothes, multiple unfinished projects). The mood disturbance was sufficiently severe to impair occupational and social functioning (Criterion C) and not due to other drugs or medical conditions (Criterion D/E). Most recent episode manic, moderate severity (specifier). She has also had the following episodes since was 29 years old. The family disruption from divorce is included in Z63.5 for stress. Family psychiatric history and non-compliance with medication are supportive of this diagnosis. The diagnosis of cyclothymia or schizoaffective disorder was excluded because they had complete manic episodes and no psychosis.
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Inductive Reasoning & Theoretical Orientation
Definition: Bottom-up process building patterns from observations to conceptualization ((Moskow et al., 2023).
The course Selected Orientation: Cognitive Behavioral Therapy (CBT) for bipolar disorder is designed for practitioners who are interested in the CBT approach to bipolar disorder (Freeman, 2025).
Thought Distortion: During the mood states: addresses distorted thoughts and increases coping skills
Purpose: Psychoeducational, mood monitoring, sleep hygiene, relapse prevention
Fits Sarah: Medication adherence, impulsive spending, stress management
Positive: Makes use of her knowledge and inspiration to support kids
Inductive reasoning takes the specific data collected from the client (symptoms, history, behaviors) and leads to a general case conceptualization and treatment plan (Moskow et al., 2023). Specific observations (racing thoughts, impulsive spending, poor sleep, feelings of guilt) form a pattern of mood dysregulation that is driven by biological vulnerability and psychosocial stressors for Sarah. CBT is the most evidence-based theoretical orientation, as it will assist clients in identifying and changing their negative thinking patterns that can lead to either mania or depression and will provide them with behavior strategies (Freeman, 2025). It facilitates assessment via group-based monitoring of mood, conceptualization of vulnerability-stress and treatment in the form of structured interventions such as relapse prevention planning and financial boundary work. This is appropriate for Sarah considering her general awareness, drive to stability and past track record of functioning well during periods of mood stability. Along with medication management, CBT can include family involvement and lead to long-term mood stability and functioning for her and her children.
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Cultural Formulation (CF)
Gender: female, Caucasian
Cultural Explanation of Illness: Views bipolar as medical, feels shame/stigma.
Psychosocial stressors: Divorce, parenting stress and financial stress post-mania
Eliminate embarrassment that hinders social interaction due to cultural factors affecting self-concept & relations.
Spiritual / Religious considerations – Acceptable to include spiritual / religious hope and purpose
Overall Impact: Influences help-seeking, adherence, recovery goals
Z-Codes per DSM-5-TR (pp. 979-982)
Sarah's cultural identity as a 45-year-old Caucasian divorced mother influences her experience with the help of elements of Culture from Sperry's and Sperry's Cultural Formulation (Table 3.3). She could internalize Western attitudes towards bipolar disorder as well as cultural stigma associated with mental illness and divorce as a woman and mother. Cultural explanations: episodes are biochemical, but perceived as personal failure and/or embarrassment and thus, social withdrawal. The psychosocial stressors are single-parenting after divorce, financial problems due to overspending, and problems with employment stability. These impact on her sense of self (guilt, low motivation) and others (low engagement despite supportive sister). Spiritual and religious factors need to be taken into account; related assessments should include discussions of hope, purpose and resilience from a Christian worldview, to promote coping.
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References
Freeman, J. (2025). Exploring the feasibility and acceptability of a cognitive behavioural therapy (CBT) protocol for mood-driven, problematic impulsive behaviours in adults with bipolar disorder: A case series (Doctoral dissertation, University of Exeter). https://ore.exeter.ac.uk/articles/thesis/Exploring_the_feasibility_and_acceptability_of_a_Cognitive_Behavioural_Therapy_CBT_protocol_for_mood-driven_problematic_impulsive_behaviours_in_adults_with_bipolar_disorder_A_case_series/30174709/1/files/58371187.pdf
Moskow, D. M., Ong, C. W., Hayes, S. C., & Hofmann, S. G. (2023). Process-based therapy: A personalized approach to treatment. Journal of Experimental Psychopathology, 14(1), 20438087231152848. https://journals.sagepub.com/doi/pdf/10.1177/20438087231152848
Régent, A., Thampy, H., & Singh, M. (2023). Assessing clinical reasoning in the OSCE: pilot-testing a novel oral debrief exercise. BMC Medical Education, 23(1), 718. https://link.springer.com/content/pdf/10.1186/s12909-023-04668-5.pdf
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