CASE STUDY
Case Study Assignment: Sam
Melissa Martinez
School of Behavioral Sciences, Liberty University
Author Note
Melissa Martinez
I have no known conflict of interest to disclose.
Correspondence concerning this article should be addressed to Melissa Martinez
Email: msstroup@liberty.edu
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CASE STUDY2
Case Study Assignment: Sam
Client Concerns
Symptoms Behaviors Stressors
Mood SwingsExperiencing periods of Unknown
euphoria and periods of
overwhelming sadness.
Suicidal IdeationFeeling worthless, she might Experiencing mood swings
be better off dead, wondering and overwhelming feelings of
what it would be like to go to sadness.
sleep and never wake up, and
thinking her friends and
family would be better off if
she were dead. She does not
have a plan or a date, but she
has researched the most pain-
free methods of suicide.
SadnessLack of enjoyment and Unknown
pleasure in normal activities,
fatigue, lethargy, lack of
appetite, difficulty
concentrating, feeling
worthless, and suicidal
ideations.
EuphoriaNeeding very little sleep to Unknown
function, increased energy,
trying to write a novel and a
screenplay, spoke
consistently of being a
phenomenal author who will
be famous one day,
completed all housework and
schoolwork, and had time to
socialize.
Hallucinating Hearing voices telling her Lack of sleep and prolonged
that she was a terrible writer. manic episode
This resulted in Sam being
hysterical and crying
uncontrollably.
Assessment
One assessment used to clarify the diagnosis would be the Rapid Mood Screener (RMS).
This assessment is a 6-item self-reported screening tool that utilizes easily understood
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terminology that takes less than two minutes to complete (Thase, Stahl, McIntyre, Matthews-
Hayes, Patel, Harrington, Maletic, Jackson, & Vieta, 2021). This assessment primarily screens
for manic symptoms, a distinguishing feature of the Bipolar I Disorder criteria (Montano, Patel,
Jain, Masand, Harrington, Gillard, Sullivan, McElroy, Brown, Nelson, & McIntyre, 2021). The
RMS assessment would be more beneficial in assessing Bipolar I Disorder compared to the
widely known assessment for Bipolar Disorder, the Mood Disorder Questionnaire (MDQ),
because the MDQ has a high false negative rate. The MDQ also often fails to distinguish a
diagnosis between Bipolar Disorder and Borderline Personality Disorder due to some
overlapping symptoms (Balling, Chelminski, Dalrymple, & Zimmerman, 2019). From the RMS
assessment, the clinician would be able to screen out the possibility of a Borderline Personality
Disorder diagnosis as well as a Major Depressive Disorder diagnosis due to the sole focus of the
RMS being the manic episode symptoms in Bipolar I Disorder.
Diagnostic Impression
Sam seems to present with a diagnosis of Bipolar I Disorder, Current or Most Recent
Episode Depressed, Severe (F31.4) (American Psychiatric Association, 2022).
Signs and Symptoms
DSM-5-TR Diagnostic Criteria: Bipolar I Client's Signs/Reported Symptoms
Disorder, Current or Most Recent Episode
Depressed, Severe (F31.4)
Manic Episode
Criterion A: A period of abnormally and Sam reports that she slept one to two hours a
persistently elevated, expansive, or irritable night and would wake up with lots of energy.
mood and increased activity or energy lasting This energy resulted in her trying to write a
at least one week, nearly every day, for most novel and a screenplay. She worked on this
of the day (American Psychiatric Association,novel and screenplay for 12 days.
2022).
Criterion B: During the mood disturbance, Sam reports a significantly decreased need for
three or more of the following symptoms are sleep, would talk non-stop about how
also present and result in a noticeable change amazing of an author she is and how she will
in behavior: inflated self-esteem or be famous, and she spent excessive time
Criterion D: This episode is not attributable to
the physiological effects of a substance,
medication, or another medical condition
(American Psychiatric Association, 2022).
Major Depressive Episode
Criterion A: Five or more of the following
symptoms are present during the same two-
week period, with at least one symptom being
either a depressed mood or a loss of interest
or pleasures: depressed mood for most of the
day nearly every day, markedly diminished
interest or pleasure in activities nearly every
day, significant weight loss or decreased or
increased appetite nearly every day, insomnia
or hypersomnia nearly every day,
psychomotor agitation nearly every day,
fatigue or loss of energy nearly every day,
feelings of worthlessness or excessive or
inappropriate guilt nearly every day,
diminished ability to concentrate nearly every
day, recurrent thoughts of death, recurrent
suicidal ideation without a specific plan, or a
suicide attempt, or a specific plan of suicide
(American Psychiatric Association, 2022).
Criterion B: The symptoms cause clinically
significant distress or impairment in social,
occupational, or other areas of functioning
(American Psychiatric Association, 2022).
CASE STUDY
grandiosity, decreased need for sleep,
excessive talking, flight of ideas,
distractibility, increase in goal-directed
activity, excessive involvement in risky or
actions with potentially painful consequences
(American Psychiatric Association, 2022).
Criterion C: The mood disturbance causes
significant impairment in social or
occupational functioning or necessitates
hospitalization due to psychotic features
(American Psychiatric Association, 2022).
Sam reports that her friends comment on how
she always seems down and has isolated
herself from the friend group. She has also
reported significant trouble with school and
possibly getting removed from the social
work program that she is in due to being on
academic probation and unable to concentrate
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writing a novel and screenplay and then
talking about how it will be the best novel and
movie ever made. Sam was never interested
in English or being an author outside this
episode.
Sam reports that on the 12th day of this
episode, she started hearing voices telling her
that she was a terrible writer. She became
hysterical and cried uncontrollably, resulting
in her roommate taking her to the Emergency
Room. Sam's roommate reports that Sam was
impossible to live with during this episode,
even though they are close friends.
Sam reports that she has no history of medical
problems and has never been on medication.
She will have two or three alcoholic
beverages a week, but this is primarily on the
weekend and during social events.
Sam reports that during the current and most
recent depressive episode, she has felt sad
daily, has had little to no pleasure in her daily
activities, sleeps 12-13 hours a day, is
fatigued daily, has no appetite, feels
worthless, and has difficulty concentrating.
Recently, Sam began thinking her friends and
family would be better off if she were dead,
and she started researching the most pain-free
ways to commit suicide, but she does not
have a plan or a date. However, she said she
cannot continue to live like this long term.
CASE STUDY5
due to her depressive moods.
Criterion C: The episode is not attributable to Sam reports that she has no history of medical
the physiological effects of a substance or problems and has never been on medication.
another medical condition (American She will have two or three alcoholic
Psychiatric Association, 2022).beverages a week, but this is primarily on the
weekend and during social events.
Other DSM-5-TR Conditions Considered
Other DSM-5-TR conditions considered include Bipolar II Disorder and Major
Depressive Disorder. Regarding Bipolar II Disorder, a hypomanic and a depressive episode are
required, however, a hypomanic episode becomes a manic episode if psychotic features are
present (American Psychiatric Association, 2022). If a manic episode is present, the diagnosis
becomes Bipolar I Disorder. Due to Sam experiencing psychotic features during a manic episode,
the diagnosis of Bipolar II was ruled out. Regarding Major Depressive Disorder, Sam met some
of the criteria for this diagnosis, except Criterion E, which states that there has never been a
manic or hypomanic episode (American Psychiatric Association, 2022). Due to this criterion not
being met, this diagnosis was ruled out.
Developmental Theories and/or Systemic Factors
Sam presents in Erikson's sixth stage of psychosocial development. This stage occurs in
early adulthood and is termed Intimacy v. Isolation. In this stage, individuals seek out intimate
relationships they can establish, maintain, and promote with trustworthy people. These
individuals must build and develop relationships that allow them to acknowledge their
vulnerability (Maree, 2021).
Regarding the client's family, Sam's parents divorced when she was 14 years old. While
she has a close relationship with her mom and stepdad, she only has a decent relationship with
her dad and step-mom. Sam is also the oldest of three children. Being the oldest, Sam could feel
like she is the protector and might take on a leading role for her siblings. Regarding her parents'
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divorce, Sam notes that both her mother and her father would say that her mother's depression
was the reason for the divorce. Sam's father would constantly say that he did not marry a woman
who was depressed, and he could not picture spending the rest of his life with someone so sad all
the time. The reason for her parent's divorce, her father's opinion on depression and relationships,
and the role she takes regarding her siblings all support why Sam says she cannot be completely
honest with her family about her issues with manic and depressive episodes. Sam's mother and
sister both have untreated depression. Being that the depression is untreated, there is a possibility
that they also have a Bipolar Related Disorder but are just not aware of it, thus resulting in a
possible genetic factor.
Multicultural and/or Social Justice Considerations
Multicultural and social justice concerns do not appear to have influenced Sam's
presenting problems.
Treatment Recommendations
Key Issues for Treatment
Suicidal Ideation
Depressive Moods
Manic Moods
Recommendations for Individual Counseling
Two treatment recommendations for the key issues for treatment include Interpersonal
and Social Rhythm Therapy and Cognitive-Behavioral Therapy. Interpersonal and Social
Rhythm Therapy addresses the client's adherence to possible medication, identification of
stressors, and establishment of daily routines. This treatment helps improve the client's overall
mood and functioning and teaches them skills that help prevent relapse (Hoberg, Ponto, Nelson,
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and Frye, 2013). Cognitive-Behavioral Therapy teaches the client education about the illness,
how to detect early warning signs of relapse, social skills training, conflict resolution, self-
esteem building, activity planning, and how to restructure potentially harmful cognitive thoughts
and feelings (Hoberg et al., 2013). Lastly, Sam indicates that her faith in God is very important to
her, and she would like to integrate it into the therapy process. Utilizing mindfulness along with
incorporating faith in God could be incredibly beneficial for Sam. Sam would benefit from
knowing that she is not alone, that she is God's creation, and that there is nothing wrong with her.
Hebrews 10:35-36 (NIV, 2011) states, "So do not throw away your confidence; it will be richly
rewarded. You need to persevere so that when you have done the will of God, you will receive
what he has promised."
Specific Considerations
Having a client in crisis changes the focus of a clinician's assessment and treatment
planning. The client being in crisis requires the clinician to determine a shorter-term treatment
plan that is effective due to the urgency to stabilize the client. Once the client is stabilized to no
longer be in crisis, longer-term treatment can be addressed. The clinician needs to find out if the
client has a plan of suicide and if they are a danger to themselves or others. Having a client in
crisis also affects a clinician's diagnosis. When a client is in crisis, the clinician might primarily
focus on the crisis at hand and could oversee the underlying symptoms that have led to the crisis.
This could make misdiagnosing a concern. It is crucial to ensure the safety of the client in crisis
and complete a full assessment of all the presenting problems.
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References
American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental
Disorders (5th ed., Text Revision). American Psychiatric Association Publishing.
Balling, C., Chelminski, I., Dalrymple, K., & Zimmerman, M. (2019). Differentiating borderline
personality from bipolar disorder with the mood disorder questionnaire (MDQ): A
replication and extension of the international mood network (IMN) nosology project.
Comprehensive Psychiatry, 88, 49-51. https://doi.org/10.1016/j.comppsych.2018.11.009
Hoberg, A. A., Ponto, J., Nelson, P. J., & Frye, M. A. (2013). Group interpersonal and social
rhythm therapy for bipolar depression. Perspectives in Psychiatric Care, 49(4), 226-234.
https://doi.org/10.1111/ppc.12008
Holy Bible: New International Version. (2011). Grand Rapids, MI: Biblica
Maree, J. G. (2021). The psychosocial development theory of erik erikson: Critical overview.
Early Child Development and Care, 191(7-8), 1107-1121.
https://doi.org/10.1080/03004430.2020.1845163
Montano, C. B., Patel, M., Jain, R., Masand, P. S., Harrington, A., Gillard, P., Sullivan, K.,
McElroy, S. L., Brown, T. M., Nelson, L., & McIntyre, R. S. (2021). The rapid mood
screener: A novel and pragmatic screener tool for bipolar I disorder. CNS Spectrums,
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Thase, M. E., Stahl, S. M., McIntyre, R. S., Matthews-Hayes, T., Patel, M., Harrington, A.,
Maletic, V., Jackson, W. c., & Vieta, E. (2021). Healthcare provider perspectives on
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