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Case Study Assignment: Sam
Introduction
This case study aims to develop a comprehensive assessment and development of a
patient-centered treatment plan for Sam, who is a 25-year-old female patient of Caucasian origin
who presents with suicidal ideation and severe mood swings. This essential approach addresses
the patient's concerns, the diagnostic impression, and recommended treatment, among other
critical aspects to understand about the patient. The report is vital to understanding the real-life
management of patients from a theoretical angle, which helps improve the overall competency to
manage complex patient cases.
Client Concerns
Sam presents with a series of concerning behaviors and symptoms that have a significant
implication for her daily life activities and her overall well-being. Some of these concerns are
outlined.
Symptoms Behaviors Stressors
Sadness Trouble sleeping (1 to 2 hours during manic episodes
and 10-12 hours during the depressive periods.
Risk of being removed from her
master’s program due to low
grades
Fatigue Isolation Conflicts with her roommate
No appetite Tearfulness Strain on friendship
Hopelessness Difficulty in concentrating History of depression in her
family
Worthlessness Withdrawal from social activities Academic probation
Suicidal thoughts Crying uncontrollably Mothers struggle with
depression
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Hallucinations
during the manic
episode
Excessive writing during the manic episode Recent breakup in a serious
romantic relationship
High energy during
the manic episode
Assessment
For Sam's case, the Beck Depression inventory-II is a significant tool that can be used to
assess her depressive symptoms. The tool is a 21-item self-report measures that evaluate the
severity and presence of depressive symptoms such as worthlessness, sadness, and hopelessness.
The BDI-II tool was chosen due to the strong empirical report, ease of use, and the ability to
offer detailed information on the patient’s research, suggesting the need to use Beck depression
inventory-II in the measurement of depression among patients with bipolar one disorder. It is
also essential to use another tool, like the Young Mania Rating Scale, a gold standard measure in
manic symptom assessment among such a patient like Sam. Because its clinical meaning in
scores is not well established, the Beck inventory tool is more reliable in assessing mood
disorders (Samara et al., 2023).
Diagnostic Impression
Bipolar one disorder: ICD code (F31.4) current episode depressed, severe with no
psychotic manifestation.
The diagnostic impression for Sam is bipolar disorder, where she presents with a
depressed episode. Bipolar disorder is also referred to as manic depression or manic depression
illness, which is a mental illness causing shifts in the person's energy levels, mood,
concentration, and activity ;(National Institute of Mental Health, 2024). This shift results in poor
performance among the affected individuals. Bipolar One disorder has criteria for manic
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episodes for about seven days or manic episodes that are so severe that one needs immediate
care, with the depressive phase taking at least two weeks period ;(National Institute of Mental
Health, 2024). If a patient experiences repeated four or more episodes of depression or mania
within one year, this is called "rapid cycling" ;(National Institute of Mental Health, 2024).
Signs and Symptoms
DSM-5-TR Diagnostic Criteria: Bipolar
one disorder: ICD code (F31.4) current episode
depressed, severe with no psychotic
manifestation.
Client’s Signs/Reported Symptoms:
Criterion A: at least one manic episode, which is
preceded by a major depressive or hypomanic
episode (APA, 2013).
The patient reports a history of episodes with
Excessive writing, elevated mood, hallucinations
during manic periods, and decreased need for
sleep (American Psychiatric Association, 2013).
Criterion B: Reports of a Depressive episode Fatigue, hopelessness, sadness, difficulty
concentrating, reduced appetite, hopelessness, and
suicidal ideations.
Criterion C: Significant impairment Academic probation, relationship strain, and risk
of being removed from the master’s class
Criterion D: No attributable causes from The patient has no history of medical conditions,
physical injuries, or substance abuse, which can
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substance abuse or other physical conditions
The manic hypomanic or major depressive
episode can not be better explained by psychotic
disorder, schizophrenia spectrum,
schizophreniform disorder, or schizoaffective
disorder (DSM-5 criteria) (APA, 2013).
explain her condition. There is an adverse history
of schizophrenia and spectrum disorders, which
can be attributed to the patient's manifestations.
Criterion E: duration The depressive episodes last for months, while
the manic episodes last from days to weeks.
According to DSM-5 criteria, during the manic or hypomanic episode, the patients
present with elevated or expansive mood, grandiosity, flight of ideas, increased energy, reduced
need for sleep, and over-talkativeness (Jain & Mitra, 2023). During the depressive episode, they
manifest with anhedonia, prominent depressed mood, suicidal ideation, feelings of
worthlessness, and loss of energy (Jain & Mitra, 2023). Based on the clinical manifestation for
Sam, the most probable diagnosis considering her situation is bipolar one disorder.
Other DSM-5-TR Conditions Considered
For Sam, some other considerable diagnoses include;-
i. Major depressive disorder: Various clinical features such as fatigue, low mood,
low self-esteem, hopelessness, suicidal ideations, and lack of appetite support the
diagnosis of major depressive disorder, which is, however, ruled out due to the
history of mania which is exhibited by the reduced need for sleep, elevated mood,
hallucinations, and excessive writing which are indicative of bipolar one disorder.
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ii. Generalized anxiety disorder: The patient worries about her academic and social
relationships, which, combined with the issues of difficulty sleeping and poor
concentration, points toward generalized anxiety disorder (American Psychiatric
Association, 2013). The disorder is, however, excluded since the issues are not
centered around chronic anxiety and worry but rather are linked to her mood
swings, in particular during the manic episode where there is elevated mood.
Also, the presence of hallucinations and manic symptoms further points to bipolar
one disorder over anxiety disorder.
iii. Borderline personality disorder: Borderline personality disorder is a condition that
is characterized by a pervasive pattern of instability in self-image, affect, and
interpersonal relations, while it is marked by impulsiveness. The patient's fear of
abandonment, mood swings, and intense emotional response could indicate
borderline personality disorder. Despite the symptoms such as impulsiveness and
mood instability overlap, the presence of depressive episodes and manic periods is
more distinct for bipolar one disorder. Borderline personality disorder often
involves rapid mood shifts and chronic instability, which is due to environmental
triggers rather than mood changes present among bipolar one patients (American
Psychiatric Association, 2013).
iv. Schizoaffective disorder: schizoaffective disorder is a condition that involves
symptoms of mood disorder and schizophrenia. Hallucinations by Sam during the
manic episodes suggest a psychotic disorder, such as a schizoaffective problem.
The condition is, however, ruled out because her hallucinations are tied to manic
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episodes and do not occur independently of the mood concerns, which is a
significant concern for schizoaffective disorder.
Developmental Theories and Systemic Factors
According to Erikson's stages of development, the most suitable stage for Sam is
"intimacy versus isolation," which is essential for her academic achievements and relationship
status ;(Orenstein & Lewis, 2022). During this stage, an individual seeks love and
maldevelopment, where one forms close friendships and long-term relationships ;(Orenstein &
Lewis, 2022). Failure to achieve this isolates someone;(Orenstein & Lewis, 2022). Her struggle
with mood instability, which affects her intimate life and academic prowess, is a significant issue
for the patients. Also, the patients have a well-established family history of depression, which is
attributed to her developmental history; this indicates her current condition. Engaging in conflict
with her roommate, who is her close friend, suggests her inability to maintain a healthy
relationship. The strain in her social relationship further complicates her sense of hopelessness
and isolation, which is worsened by her fear of course termination and worry of being seen as a '
mentally ill person".
According to the family systems theory by Murray Bowen, this emphasizes the need for
the family as an emotional unit to influence someone’s behaviors (An et al., 2024). The patient’s
family history could have impaired her overall mental health and behavior patterns, which can be
attributed to the mother’s long-term depression caused by divorce, which is a significant factor to
consider. Due to the depressive episodes of her mother, this could have created an unstable home
environment during her formative years, Sam, hence affecting her health. The statement that her
father was unable to bear with the mother's mental illnesses and thus divorced her suggests a core
source of conflict and stress. A child’s mental framework is often affected by paternal and
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maternal warmth and hostility, determining their executive performance as they develop (An et
al., 2024). This also contributes to her feeling of worthlessness and reluctance to seek help
because she fears the stigma associated with mental health, considering her mother’s experiences
(An et al., 2024). Overall, the family is a significant unit for the individual's mental health.
Family support and presence are associated with better emotional support and performance,
social health, and psychological wellness.
Multicultural and Social Justice Considerations
The RESPECT model is effective in patient assessment since it helps one remember what
factors need to be considered to ensure the patient is engaged in a linguistically and culturally
competent manner. Such factors are essential during assessment, diagnosis, and treatment, where
one understands how respect is offered among various groups of patients.
For the case of Sam, the issues of choice are family background or history, which is a
fundamental consideration among mentally ill patients. The patient’s family background is full
of significant mental health concerns and family instability; where her mother had a long-term
battle with depression, which led to divorce from her husband. Bearing in mind that family is a
significant family support for the children, this profoundly affected Sam’s well-being, which
contributed to her fear of stigma and worthlessness. Her fear of mental illness stigma can be
attributed to her father’s unwillingness to support her mother following her depression, which
has impacted Sam's reluctance to seek help and cope with her condition (Alluhaibi & Awadalla,
2022). From the cultural angle, Sam internalizes the issues of mental illness as a source of
weakness and shame, reflecting her father’s view. This is a significant consideration where the
beliefs exacerbate mental illnesses and limit one’s healthcare-seeking practices (Alluhaibi &
Awadalla, 2022). Often, mental illness stigma results in negative attitudes towards mental
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healthcare-seeking behaviors and self-esteem, where her fear of "mental illness” is a supportive
attribute.
During the care process for Sam, it is essential to consider her family background and history as
significant issues that determine her current situation and a barrier to treatment processes.
Understanding aspects such as exacerbated mood swings, which are linked to parental
separation, is essential to address aspects of individual psychological support for the patient in
response to stigmatization and family patterns.
Treatment Recommendations
Key Issues for Treatment
i. Suicidal ideation
ii. Severe depressive symptoms
iii. Mood instability
Recommendations for Individual Counseling
In the management of Sam, it is essential to consider counseling as a significant treatment
approach for patients with mental illnesses such as bipolar disorder. On this note, the first
recommendation is cognitive behavior therapy, which is a considerable approach that will help
Sam determine and address her negative thought processes, which result in her depressive state.
Cognitive behavioral therapy involves various techniques, including cognitive restructuring and
behavioral activation, which help alleviate the patients’ problems and enhance their overall
functioning. The approach has been found helpful in managing the patients’ actions and
thoughts, where it helps manage all types of bipolar disorder except during an acute mania,
which occurs as a severe and sudden condition (Özdel et al., 2021). The role of cognitive
behavioral therapy in the management of the condition has a significant contribution to the
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overall treatment since it helps erase the disease symptoms such as irritability and elevated
mood, enhances adherence to drug therapy, helps the patient to develop skills to determine early
signs and prevent the occurrence of an episode, and helps in managing comorbid conditions like
anxiety disorder (Özdel et al., 2021). Secondly, the patient needs to be managed by the use of
dialectal behavioral therapy, where bipolar patients can develop competency in regulating
emotions, reducing impulsivity, and being more mindful ;(Jones et al., 2023). By addressing the
underlying emotional issues that occur among bipolar patients, dialectal behavioral therapy is
helpful to the patient to live a more fulfilling and balanced life;(Jones et al., 2023). This is
supported by research evidence that dialectal behavioral therapy helps one develop mindfulness
skills, interpersonal competence, emotional regulation skills, and the ability to deal with various
distress. The treatment was initially designed to help manage borderline personality disorder,
which has overlapping symptoms with bipolar disorder, including suicidality, impulsiveness, and
mood instability ;(Jones et al., 2023). On this assertion, various clinicians and researchers have
found DBT to be an effective intervention to enhance symptom awareness and mood change
control, improving overall health-seeking and adherence behaviors.
Medication consideration
It is essential to refer Sam for medical evaluation to help address the severe depressive
symptoms such as suicidal ideation and mood instability aspects. Various drugs, such as lithium,
which is a mood stabilizer, and antidepressants, such as citalopram, fluoxetine, paroxetine, and
escitalopram, are essential for the management of patients. Lithium is the drug of choice for the
management of patients during the depressive phase, which needs to be considered ;(NHS,
2021). It is essential to consider combination therapy, where the drug therapy is administered in
conjunction with the psychotherapy approach, such as cognitive behavioral therapy, which helps
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offer optimal care for the patients. The aim of the drugs here is to stabilize the patient’s mood,
address his depressive symptoms, and prevent any future manic or depressive episodes ;(NHS,
2021). Among the patient, it is essential to monitor various side effects such as agitation, rashes,
insomnia, nausea, and nervousness, especially when on antidepressant therapy. When managing
such patients, it is essential to address their characteristics, such as cycling patterns, treatment
history, and current mood, which help determine what treatment approach to embrace for the
best patient outcome.
Specific Considerations
A patient in a crisis such as Sam's needs immediate stabilization and a safety plan,
especially considering issues such as suicidal ideations. A crisis intervention addresses the
immediate risk and stabilizes the patient's symptoms. Due to suicidal tendencies, it is essential to
consider a safety plan for the patient and possibly hospitalization to reduce the risk of harm. The
main aim of crisis management is to develop a primary goal of stabilizing the patients before
planning for care and carrying out any assessments ;(Shah et al., 2019). This involves taking
safety assessments such as the presence of any self-harm tools, check-ins to determine the
patient's state and response, and offering a short-term drug that helps manage acute symptoms
such as low mood. The use of drugs such as lithium, quetiapine, and lamotrigine could be
considered, while in severe cases, combining valproate and lithium is considered ;(Shah et al.,
2019).
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References
Alluhaibi, B. A., & Awadalla, A. W. (2022). Attitudes and stigma toward seeking psychological
help among Saudi Adults.;BMC psychology,;10(1), 216. https://doi.org/10.1186/s40359-
022-00923-4
American Psychiatric Association. (2013).Diagnostic and statistical manual of
mental disorders(5th ed.).
https://doi.org/10.1176/appi.books.9780890425596
Jain, A., & Mitra, P. (2023, February 20).;Bipolar Disorder. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK558998/
Jones, B. D. M., Umer, M., Kittur, M. E., Finkelstein, O., Xue, S., Dimick, M. K., Ortiz, A.,
Goldstein, B. I., Mulsant, B. H., & Husain, M. I. (2023). A systematic review on the
effectiveness of dialectical behavior therapy for improving mood symptoms in bipolar
disorders.;International Journal of Bipolar Disorders,;11(1).
https://doi.org/10.1186/s40345-023-00288-6
National Institute of Mental Health. (2024, February).;Bipolar Disorder - National Institute of
Mental Health (NIMH). Www.nimh.nih.gov.
https://www.nimh.nih.gov/health/topics/bipolar-disorder#:~:text=What%20is%20bipolar
%20disorder%3F
NHS. (2021, February 11).;Treatment - Bipolar Disorder. Nhs. Uk; Crown.
https://www.nhs.uk/mental-health/conditions/bipolar-disorder/treatment/
Orenstein, G. A., & 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/
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Özdel, K., Kart, A., & Türkçapar, M. H. (2021). Cognitive Behavioral Therapy in Treatment of
Bipolar Disorder.;Noro psikiyatri arsivi,;58(Suppl 1), S66–S76.
https://doi.org/10.29399/npa.27419
Samara, M. T., Levine, S. Z., & Leucht, S. (2023). Linkage of Young Mania Rating Scale to
Clinical Global Impression Scale to Enhance Utility in Clinical Practice and Research
Trials.;Pharmacopsychiatry,;56(1), 18–24. https://doi.org/10.1055/a-1841-6672
Shah, N., Grover, S., & Rao, Gp. (2019). Clinical practice guidelines for management of bipolar
disorder.;Indian Journal of Psychiatry,;59(5), 51. https://doi.org/10.4103/0019-
5545.196974
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