CASE STUDY: SAM 1
Case Study: Sam
Destinee Chavis
School of Behavioral Science, Liberty University
Author Note
Destinee Chavis
I have no known conflict of interest to disclose.
Correspondence concerning this article should be addressed to Destinee Chavis
Email: dmchavis1@liberty.edu
CASE STUDY: SAM 2
Client Concerns
Symptoms Behaviors Stressors
Mood Dysregulation Inability to focus Possibility of being removed
from master’s program
Sadness Suicidal ideations (passive
planning)
Roommate threatening to
move out.
Decrease in appetite Grandiose thinking Internship for school.
Lethargic Isolation Fear of being judged by the
faculty within the program.
Fatigue/Insomnia Inability to complete
schoolwork/Attend class
Emotional strain on her
friendships
Hopelessness/Worthless Minimizing the seriousness
of her condition.
Auditory Hallucinations
Assessment
Sam presents with severe bipolar depressive symptoms. She has been experiencing these
symptoms for at least two years. Sam reports periods of “high” episodes where she feels like
herself and can get things done, however after a period of about two weeks she begins to feel
depressed again. Based on the self-report from Sam, I would use the Mood Disorder
Questionnaire (MDQ) to assess her case. The MDQ is a screening tool that is used to screen
bipolar disorder. It was developed by Robert Hirschfeld and colleagues in 2000 and consists of
13 statements to identify whether hypomanic or mani symptoms are present with the individual
completing the screening (Wang et al., 2020). I believe that this assessment would be beneficial
because it would highlight some of the symptoms that Sam is experiencing that she may be
overlooking or afraid to disclose. The MDQ also considers the lifelong presence of manic
symptoms, not only current ones, which is good for Sam because she has reported difficulties
with her moods.
CASE STUDY: SAM 3
Diagnostic Impression
Sam is presenting with symptoms and behaviors that are consistent with a DSM-5
diagnosis of Bipolar I Disorder, Current Episode Depressed, Severe with Psychotic features
296.54A(F31.4). The DSM-5 states that clients that are diagnosed with Bipolar 1 must have at
least one manic episode lasting at least one week (APA, 2022). Sam reported that one episode
lasted 12 days. The symptoms that she reported correlate to the Bipolar I diagnosis. Sam could
also be diagnosed with Major Depressive Disorder due to her depressive episodes. However, this
diagnosis does not acknowledge mania or psychotic features.
Signs and Symptoms
DSM-5-TR Diagnostic Criteria of: Bipolar I
Disorder, Current Episode Depressed, Severe
with Psychotic features 296.54'(F31.4)
Client’s Signs/Reported Symptoms:
Criterion A: A distinct period of abnormally
elevated, expansive, or irritable mood and
abnormally and persistently increased activity
or energy, lasting at least 1 week (or any
duration if hospitalization is necessary).
The client reports 12-day period of manic
episode where she only slept 1-2 hours a
night. She also reported writing her novel for
10 hours a day. Which led to her roommate
taking her to the ER.
Criterion B: During the disturbance three or
more of these symptoms are present and
represent a noticeable change:
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep.
3. More talkative than usual or pressure to
keep talking.
4. Flight of ideas
5. Distractibility
6. Increase in goal-directed activity (social,
work or school)
7. Excessive involvement in activities that
have a high potential for painful
consequences.
The client reports she would write her novel
for at least 10 hours a day, resulting in 1-2
hours of sleep at night. She reported having
thoughts of being the “world’s greatest
author.” She became hyper focused on
completing the novel so that she could move
on to the screenplay.
Criterion C: The mood disturbance is
sufficiently severe to cause marked
impairment in social or occupational
functioning or to necessitate hospitalization to
prevent harm to self or others, or there are
psychotic features.
The client reports that she has not been able to
complete her schoolwork. Her friendships are
suffering due to her increase in symptoms.
She has researched different ways to commit
suicide and reports auditory hallucinations
causing her roommate to take her to the ER.
CASE STUDY: SAM 4
Criterion D: The episode is not attributable to
the physiological effects of a substance.
The client does not report any substance use
and very minimal alcohol consumption.
Criterion E: The disturbance cannot be
attributed to the physiological effect of a
substance (drug abuse or medication) or
another medical condition.
The client does not report any symptoms that
relate to any psychological disorders. (i.e.,
Bipolar I or schizoaffective disorder)
Criterion F: The disturbance is not better
explained by another mental disorder.
Other DSM-5-TR Conditions Considered
Sam reported a period of sadness during these episodes. She reported that it made her sad
when her roommate threatened to move out. During the interview she was tearful when
discussing her relationship with her roommate, as she described her roommate as her closest
friend. Sam reported being fatigued from sleeping long hours sometimes, changes to her appetite
and feeling worthless. She also stated that sometimes she wishes she could fall asleep and never
wake up. These symptoms could be related to Major Depressive Disorder as outlined in the
DSM-5. After reviewing the criteria for that diagnosis, I realized that it would not be appropriate
to diagnose Sam with depression. MDD does not involve manic or psychotic features. In the
past, Sam has had at least one clear manic episode which makes Bipolar I the better diagnosis.
Developmental Theories and/or Systemic Factors
Sam is a 25-year-old female, who is currently pursing her master’s degree in social work.
She has a small circle of friends but appears to be closest to her roommate and her mother. If the
clinician were to assess Sam’s case using Erikson’s Psychosocial Development Theory, they
would likely say that she is in the stage of Intimacy vs. Isolation. This period refers to the
individuals forming meaningful relationships and starting to develop a sense of identity in their
career and personal life (Orenstein & Lewis, 2022). Sam is currently faced with academic
CASE STUDY: SAM 5
instability and struggling to maintain her friendships, which suggests that she is having
difficulties evolving in this stage.
There are several systemic factors that affect Sam as well. For example, Sam has a
negative stigma surrounding mental health and her future occupation. In the interview Sam
states, “mentally ill people can’t be social workers,” which appears to increase the shame she
feels about her current condition and the avoidance to seek the support of the faculty at school.
Alongside this perspective, Sam is facing academic probation and fears being removed from the
program which contribute to her feelings of worthlessness. She also mentions her mother and
sister experiencing depression. Her parents divorced because of the severity of her mother’s
depression, which could have affected the way Sam perceives mental health as well. Sam
minimizes her symptoms because she fears telling her family the truth. She has a strong support
system; however, the severity of her episodes has strained her relationships and the fear of losing
those close to her increases her distress.
Multicultural and/or Social Justice Considerations
Sam identifies as a Caucasian female. In the interview she reports that both her mother
and sister have experiences with depression but have never received treatment for their
symptoms. This behavior could reflect a family culture to minimizing mental illness. This could
also be a contributing factor to why Sam is reluctant to receive treatment as well. Internalized
stigma can severely delay access to care and have a negative effect on treatment engagement
(Corrigan et al., 2014). Sam reported that she was given antidepressant medication in the past but
terminated the use once she began to feel better. She also did not attend her follow-up
CASE STUDY: SAM 6
appointment for psychiatric care. It was not until her roommate threatened to move out that Sam
began to seek help for her mental health.
Treatment Recommendations
Key Issues for Treatment
Sam presents with clear episodes of mania and depression, including psychotic features
and suicidal ideation.
Sam lacks full awareness of her diagnosis.
Sam is at risk of being removed from her MSW program.
Recommendations for Individual Counseling
It is recommended that Sam participate in Cognitive Behavioral Therapy and or
Interpersonal and Social Rhythm Therapy. CBT is most popularly used alongside medication
treatment for clients that are diagnosed with Bipolar Disorder (Özdel et al., 2021). Significantly,
cognitive behavioral therapy helps clients with BD by easing the symptoms and helping them
learn the early signs of an episode. This process can teach Sam to regulate her emotions during
elevated states and seek help when she recognizes she may be having an episode.
The use of Interpersonal and Social Rhythm Therapy can be beneficial for Sam because it
can teach her how to recognize her interpersonal stressors and how to maintain a stable daily
routine. IPSRT is known to improve the manic symptoms in receiving patients (Steardo et al.,
2020). Research shows that this treatment has improved circadian rhythm in receiving clients as
well. This is helpful for Sam because she will be able to develop and track her “sleep-wake’
cycle to aid in better sleep patterns. Once she has learned to acknowledge her interpersonal
CASE STUDY: SAM 7
triggers, she will be able to improve her communication skills and mend the strained
relationships with her family and friends.
Sam has disclosed that she no longer takes the medication that she was prescribed to
manage her depressive symptoms. I would recommend that Sam be prescribed medication to
work alongside her therapy treatment as research has proven that the two together have positive
outcomes for clients with BD. It can also reduce episodes in BD clients.
For over 70 years, Lithium has been the number one prescribed medication for patients
diagnosed with Bipolar Disorder (Volkmann et al., 2020). Lithium is prescribed as a preventative
aid in reducing manic episodes and relapses. It is a medication that can be used regardless of age.
If Sam is prescribed Lithium, it is likely that her manic episodes will remain in remission. The
key to relapse prevention for Sam will be her ability to comply with treatment regardless of how
good she feels.
Special Considerations
When a client such as Sam is in crisis the immediate focus becomes her safety. Before
completing a full assessment, there is an immediate need to assess the risk of harm to herself or
someone else. The clinician must evaluate suicidal ideations, intent, plans, access to means and
protective measures. Depending on the severity of the crisis the clinician may have to pause
diagnostic exploration until safety is ensured for all involved parties.
Crises can affect the client’s short term vs. long term functioning. It may also exaggerate
or minimize diagnosis. For example, a person who just witnessed a traumatic experience may
CASE STUDY: SAM 8
appear manic or psychotic until they are stabilized. This can lead to a misdiagnosis or
underdiagnosis, especially for clients with Bipolar Disorder.
CASE STUDY: SAM 9
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders
(5th-TR). American Psychiatric Association.
Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The Impact of Mental Illness Stigma on
Seeking and Participating in Mental Health Care. Psychological Science in the Public
Interest, 15(2), 37–70. https://doi.org/10.1177/1529100614531398
Orenstein, G., & Lewis, L. (2022, November 7). Erikson’s Stages of Psychosocial Development.
National Library of Medicine; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK556096/
Özdel, K., Kart, A., & Türkçapar, M. H. (2021). Cognitive Behavioral Therapy in Treatment of
Bipolar Disorder. Archives of Neuropsychiatry, 58(1), 66–76.
https://doi.org/10.29399/npa.27419
Steardo, L., Luciano, M., Sampogna, G., Zinno, F., Saviano, P., Staltari, F., Segura Garcia, C.,
De Fazio, P., & Fiorillo, A. (2020). Efficacy of the interpersonal and social rhythm
therapy (IPSRT) in patients with bipolar disorder: results from a real-world, controlled
trial. Annals of General Psychiatry, 19(1). https://doi.org/10.1186/s12991-020-00266-7
Volkmann, C., Bschor, T., & Köhler, S. (2020). Lithium Treatment over the Lifespan in Bipolar
Disorders. Frontiers in Psychiatry, 11(377). https://doi.org/10.3389/fpsyt.2020.00377
Wang, H. R., Bahk, W.-M., Yoon, B.-H., Kim, M.-D., Jung, Y.-E., Min, K. J., Hong, J., & Woo,
Y. S. (2020). The Influence of Current Mood States on Screening Accuracy of the Mood
Disorder Questionnaire. Clinical Psychopharmacology and Neuroscience, 18(1), 25–31.
https://doi.org/10.9758/cpn.2020.18.1.25
