NUR 620

Reply from Daniela Barbeito Bipolar Case Discussion

Clinical Case Summary

Jill is a 24-year-old Hispanic woman that appeared in the emergency department due to radical change in behavioral orientation on her part as described by her parents. She has been giving everything away and insists that she is going to South Pole to rescue the world which is an indication of delusional and grandiose thought. According to the parents, she has been hardly sleeping in the past 7 days, she is very energetic. During the clinical interview, she seems to be pressured and talkative, uncontrollable laugher, and difficulties in sitting down and are reflective of psychomotor agitation. It is extremely difficult to make her stop and even she does not seem to have the ability to stay long enough to pay attention to provide answers to questions accordingly. These findings are consistent with a manic episode that constitutes mood and psychotic symptoms which necessitate an urgent intervention (Wiebe et al., 2022). Primary and Differential Diagnoses

Bipolar I Disorder, Current Episode Manic, With Psychotic Features (DSM-5 296.44; ICD-10 F31.2) is the initial diagnosis of Jill. This is supported by her symptoms of decreased sleep drive, bombast, abundant energy, impulsiveness and delusional beliefs (Nierenberg et al., 2023). Among various diagnoses to consider is the Schizoaffective Disorder, Bipolar Type (DSM-5 295.70; ICD-10 F25.0) which can be characterized with psychotic symptoms and at the same time mood swings, but in her case, her symptoms appear as a mood episode and not as a persistent problem. The next similar diagnosis is the case of Substance/Medication-Induced Bipolar and Related Disorder (DSM-5 292.84; ICD-10 F06.33) because mania may appear when stimulants and drugs are used, and the diagnosis is to be excluded with the help of toxicology test (Nierenberg et al., 2023). However, the history of her mother and father shows that there is no substance consumption, but it is endogenous mood disorder. This is an essential requirement because it would be necessary to offer the appropriate diagnosis and specialized therapy.

Pharmacological Treatment

Pharmacological therapy using a mood stabilizer as prescribed by the APA and CANMAT guidelines should be the first-line treatment of Jill and in this instance, lithium carbonate is the first-line drug. Lithium has been historically proved to be useful in the treatment of acute manic episode and prevention of relapse as well as minimization of the chances of suicide (Wiebe et al., 2022). The symptoms that Jill had are severe, and the symptoms observed are a result of psychotic in nature and thus it is appropriate to prescribe atypical antipsychotic medicine, such as risperidone or olanzapine. These antipsychotics have a quicker response compared to the lithium in the alleviation of the agitation, delusions and disorganized behavior. The combination therapy is also widely prescribed in case of acute mania with psychosis as not only the mood is treated but the symptoms as well are cured quickly. The lithium level, kidney

and thyroid activity would also be under strict monitoring to enable her to have good care of her condition.

Non-Pharmacological Treatment

To the recovery and relapses prevention of Jill, non-pharmacological interventions play an important role. Psychoeducation should be undertaken with Jill and her family to enable them to be better informed about the bipolar disorder and the necessity of taking medication regularly and to be more conscious about the onset of relapse. Cognitive Behavioral Therapy (CBT) would help her in doubting the distorted beliefs, have a higher level of insight and develop coping mechanisms that will help her overcome stressors that might cause future incidences (Wiebe et al., 2022). The Family-Focused Therapy (FFT) reveals much evidence of family communication, relapse prevention, and treatment compliance which would prove very helpful based on the role played by her parents in her treatment process. The initially secure hospitalization could be inpatient to ensure her safety and provide the intensive stabilization since she is giving away the possessions and has poor judgment. There would be a need to follow up with outpatient therapy after the stabilization in order to maintain the development. Such psychosocial interventions present the best chance to stabilize in the event of their combination with medication.

Health Promotion Intervention

The best health promotion that could be offered to Jill is the provision of lifestyle and wellness program well-structured, which would focus on sleep hygiene and routine building, stress management. The bipolar disorder is highly sensitive to sleep disturbances, but the risk of a relapse can be minimized significantly by setting the normal sleep and wake patterns. One should also adopt healthy lifestyle, physical exercises and shunning of other substances like alcohol and caffeine to make sure that the body is stable (Nierenberg et al., 2023). The other area that Jill needs to be associated with is the community support groups and culturally sensitive learning resources that can enable her to gain more knowledge about the illness and overcome the stigma. The PHC should be reinforced through the follow-up treatment of psychiatric treatment and adherence to pharmacologic as well as non-pharmacologic treatment as a long- term measure. These are the measures of health promotion that can empower Jill to take a significant part in her rehabilitation and reduce the possibilities of reoccurring episodes.

Reply from William Joseph Sierra Discussion: Bipolar Case

1. Summarize the clinical case including the significant subjective and objective data. Subjective Data:

The patient, Jill, is a 24-year-old Hispanic female. Her parents are taking her to the clinic, so an evaluation is conducted. The patient has either had manic or depressive episodes in the last week. She also wants to save the world by traveling to the South Pole, but this suggests that she would be confined to a room. She is distributing and getting rid of her belongings in the meantime. Although she still seems to be quite active, the surveyed person's parents speculate that she had severe insomnia a week prior to the survey. They also say that she laughs hysterically, talks without pausing, and appears preoccupied. The interview also revealed Jill's annoyance and restlessness.

Objective Data:

The patient reports the presence of multiple symptoms including inflated self-esteem, lack of sleep, excessive talkativeness, flight of ideas, lack of concentration, and over-engagement in activities prone to painful outcomes. In addition to dysfunction of a specific period of abnormally and persistently elevated, expansive, or irritable mood lasting at least one week (American Psychiatric Association, 2022).

2. Generate a primary and two differential diagnoses. Use the DSM5 to support the assessment. Include the DSM5 and ICD 10 codes.

The patient's primary diagnosis is bipolar disorder, specifically Most Recent Episode Manic with Psychotic Features (DSM-5 Code 296.89 and ICD-10 Code F31.81). A patient must experience a week-long manic episode in order to be eligible for a bipolar disorder diagnosis based on the Most Recent Episode Manic with Psychotic Features (American Psychiatric Association, 2022). At least three of the following symptoms had to be present: a need for less sleep, a high but irregular speech rate, egocentric delusions of exaggerated self-worth, accelerated goal-directed behavior, attention deficit, and a high level of risk-taking.

Secondly, the patient must present with at least one psychotic symptom, such as delusions or psychosis. Jill has been displaying signs of sleep deprivation, high goal-directed behavior such as trying to sell everything she owns, pressure and hurry in speech, and distractibility over the past week. She also believes she wants to save the world and has delusional fits in psychiatric disorders. As a result, the patient is diagnosed with DSM-5 Bipolar Disorder, Most Recent Episode Manic with Psychotic Features (American Psychiatric Association, 2022).

Differential diagnoses:

Schizophrenia, With Catatonia (ICD-10: (F20.2): This includes traits like pressure, emotional tension, and a rapid-fire stream of words; it also includes the presence of delusions and potential manic episodes.

Substance-induced Bipolar and Related Disorder (ICD-10: F10.14): The severity and remission involve substance abuse or withdrawal, which mimics a manic episode (American Psychiatric Association, 2022).

3. Discuss a pharmacological treatment would you prescribe? Use the clinical guidelines to support the rationale for this treatment.

Bipolar disorder is characterized by mood swings, and mood stabilizers will be necessary to treat it. They are only given to patients in order to prevent manic and maniacal episodes. According to Nath & Gupta (2024), Lithium is a drug that the Food and Drug Administration has approved to treat bipolar disorder, which includes both acute manic phases and a maintenance phase (Nath & Gupta, 2024). To alleviate Jill's manic symptoms and to promote a stable and optimal mood for the remainder of the week, lithium would be a suitable recommendation.

4. 4. Discuss non-pharmacological treatment would you prescribe? Use the clinical guidelines to support the rationale for this treatment.

One effective non-pharmacological treatment for bipolar disorder is cognitive behavioral therapy (CBT). It is crucial to remember that CBT aims to counteract undesirable behaviours and thought patterns (Özdel et al., 2021). In addition to identifying the factors that trigger bipolar episodes, cognitive behavioral therapy (CBT) helps people learn healthy coping mechanisms for stressful situations (Özdel et al., 2021).

5. Describe a health promotion intervention that would be appropriate for this patient. Health promotion interventions help to meet the need for psychoeducation. Additionally,

the intervention increases opportunities for medication compliance (Deng et al., 2022). In Jill's case, psychoeducation would be necessary for both her and her family since it would enable them to recognize the signs that her moods were shifting and seek professional help as soon as possible. To assess and precondition treatment plans, the intervention would also be necessary to improve follow-up appointments in accordance with the schedule.