Running head: CASE STUDY 1

Case Study: Eric and Bipolar Disorder I

Irena Pawlak

Keiser University

Dr. Sejal Shah

Psychopathology

April 25, 2013

Introduction

Bipolar Disorder (BPD) is a mood disorder involving periods of either depressed or

elevated and expansive moods (American Psychology Association [APA], 2000). These changes

in polarity are generally experienced as episodes of varying severity and duration. During these

episodes an individual will experience several different behaviors which, despite the mood, result

in impaired social, occupational, and/or academic functioning. In addition, individuals with BPD

have a higher rate of suicide than the general public with one in three versus one in thirty,

respectively (Leahy, 2007). Because of the variability of the course of the disease, most

individuals are not diagnosed at the onset of the disorder where the symptoms are more

manageable and the chances of deterioration are less likely (Alloy et al., 2012; Perlis, 2005). As

a result, BPD is one of the sixth leading causes of disability in the world (Miller, 2006; Price &

Marzani-Nissen, 2012).

In the United States, approximately 4.4 % of the population will experience some form of

BPD in their lifetime (Urosević, Abramson, Harmon-Jones, & Alloy, 2008). Furthermore, it is

estimated that BPD imposes a $45 billion cost to society in the United States due to subsidized

health care, economic losses due to loss of work productivity, and disability payments (Miller,

2006). Accordingly, research focusing on developing more effective treatment to ease the

individual disease burden as well as that of society is currently underway. To date, there have

been some promising studies including medication and psychosocial therapy which have proven

to reduce the severity of the disorder and improve overall functioning (Bowden et al., 2012;

Urosević et al., 2008).

Diagnosis
CASE STUDY: ERIC AND BIPOLAR 3

Eric is a 32-year old Caucasian male seeking treatment for concentration problems

arising from chronic worry and anxiety (Brown & Barlow, 2011). After a clinical assessment

focusing on symptoms, family history, longitudinal course, and treatment history and response

(Miller, 2006), I made the following 5-Axis diagnosis based on the Diagnostic and Statistical

Manual of Mental Disorders (APA, 2000):

Axis I: 296.x2 Bipolar I Disorder, Most Recent Episode

Mixed, Moderate, Recurrent, with full

interepisode recovery

300.00 Anxiety disorder, not otherwise specified

Axis II: V71.09 No diagnosis on Axis II

Axis III: None

Axis IV: Underemployed,

Problems with primary support group,

Father overly-involved and often complicit

in treatment and medication

noncompliance, Discord between

parents about treatment,

Problems with access to health care services,

prior hospitalizations resulting in inadequate

health insurance coverage

Axis V: GAF = 41 (current)

According to the current Diagnostic and Statistical Manual of Mental Disorders (4th ed.,

text rev.; DSM–IV–TR; American Psychiatric Association [APA], 2000), Eric suffered from
CASE STUDY: ERIC AND BIPOLAR 4

bipolar disorder (BPD) I and anxiety disorder not otherwise specified (NOS). Specifically,

Eric’s symptoms were consist with a mixed episode, a subtype of BPD I, which requires at least

one manic or mixed episode, where the criteria for a major depressive episode and a manic

episode are met for at least one week and cause marked impairment in functioning. In addition,

like both major depressive or manic episodes, these symptoms were not the product of substance

abuse or a general medical condition.

A major depressive episode requires meeting at least five of nine criteria throughout the

day, nearly every day for at least two weeks including: depressed mood, marked loss of interest

in a majority of everyday activities, unexplained weight gain/loss or change in appetite, marked

sleep disturbances, fatigue, lack of self-worth, concentration impairment, or suicidal ideation

resulting in clinical distress or functional impairment (APA, 2000). To qualify as a manic

episode, an individual must experience an excessively elevated, irritated, or uninhibited mood for

at least one week and display three or four (depending on whether the predominant mood is

irritation) of seven symptoms: grandiosity, sleeps less without feeling tired, subjective feeling of

racing thoughts, distractibility, increase in goal-directed activity, and engages in impulsive

reckless behavior (APA, 2000).

Although the duration of Eric’s symptoms could not be established definitely at the time

of his initial presentation, his depressed mood and simultaneous manic behaviors generally

indicative of a mixed episode, which is rare given that depressive and manic episodes are

typically clearly demarcated by one dominant mood (Hatchett, 2010). For example, Eric’s

feelings of failure, inability to concentrate, and agitated pacing are all symptoms of a depressed

mood and depressive episode. Likewise, the repetitive nature of Eric’s worries seemed

symptomatic of depression-oriented rumination about things gone wrong in his life (Auerbach,
CASE STUDY: ERIC AND BIPOLAR 5

Webb, Gardiner, & Pechtel, 2013). Conversely, Eric’s irritability, muscle tension, increased

goal-directed behavior towards getting a new job, restlessness, and racing thoughts/worries were

all symptomatic of mania. Eric’s fluctuating between both depression and mania without any

clear demarcation between dominant moods is a reliable indicator of a mixed episode (Price &

Marzani-Nissen, 2012). Furthermore, the fact that Eric was seeking treatment was a sure sign

that these symptoms were clinically significant and interfering with his ability to function.

In addition to Eric’s current state, based on his history, he had been suffering from BPD I

since his first manic episode during college. Thereafter, Eric reported additional episodes of

depression and elevated moods. Eric even reported experiencing delusions and auditory

hallucinations during certain depressive and manic episodes. However, he reported that when he

was taking his antipsychotic medications or in between episodes, he no longer experienced these

psychotic features. Likewise, Eric also stated that he no longer worried or had any failure-driven

thoughts. Based on this information, I determined that Eric suffered from recurrent BPD I

episodes with full interepisode recovery.

In addition to BPD I, Eric also displayed symptoms of anxiety. Specifically, Eric met the

DSM-IV-TR (APA, 2000) criteria for anxiety disorder, not otherwise specified (NOS). For

example, Eric indicated that when he was in remission, he only worried about the onset of a new

episode and whether his BPD medications would cause any long-term damage (Brown &

Barlow, 2011). Anxiety disorder NOS was used because I did not feel that Eric’s worries

outside of his mood episodes were racing or intrusive. Consequently, because Eric’s anxiety did

appear to meet the criteria for any specific disorder and because BPD I usually generally presents

with some form of anxiety (Bowden et al., 2012; Leahy, 2007; Perlis, 2005; Price & Marzani-
CASE STUDY: ERIC AND BIPOLAR 6

Nissen, 2012; Williams, Ruekert, & Lum, 2011), anxiety NOS was the only available option in

the DSM-IV-TR (APA, 2000).

With respect to Axis II, I did not find Eric to be suffering from any personality disorders.

Similarly, no diagnosis was made on Axis III because I did not find any evidence of a general

medical condition. On the other hand, Eric demonstrated serious psychosocial and environmental

issues relevant to his Axis I disorder. Accordingly, Axis IV includes problems related to his

employment, support group, and health care access. Based on Eric’s assessment, he had serious

issues related to his employment situation. For instance, despite graduating from college as well

as being trained as a paralegal, Eric was currently employed as a night security guard. Due to his

constant feelings of failure, the majority of which was focused on his employment status, and his

goal-oriented mania generally focused on looking for other jobs, Eric’s underemployment

definitely seemed clinically relevant. Eric’s support system was also a source of serious

problems affecting his mental health. Despite living with his parents who seemed genuinely

supported and concerned with Eric’s well-being, their behaviors were actually harmful in context

of Eric’s BPD I. For example, Eric’s father displayed characteristic expressed emotion by being

overly involved in monitoring Eric’s behavior and treatment. Research has demonstrated that

parental expressed emotion was highly correlated with the onset of a new episode as well as

longer time to remission (Miklowitz, 2008). In addition, Eric’s parents’ disagreements over his

treatment were a source of conflict and a potential stressor (Leahy, 2007; Miklowitz, 2008).

Finally, Eric’s parents’ health insurance had reached its maximum following Eric’s last

hospitalization. As a result, both he and his parents were concerned about the cost of treatment

and were often reluctant to commit Eric or take him in for treatment. Compounded by the fact

that despite all of the treatment and medications Eric had been taking over the past 13 years, his
CASE STUDY: ERIC AND BIPOLAR 7

parents were often set on keeping him at home to prevent him from deteriorating which played a

role in Eric’s periodic failure to adhere to his prescribed medication regiment.

The last Axis represents Eric’s current global assessment functioning (GAF) score. This

was calculated according to the instructions in the DSM-IV-TR (APA, 2000). Accordingly, based

on Eric’s current presentation, taking into account his clinical history which was significant for

four suicide attempts, three hospitalizations, and mood-congruent psychoses, I believe that Eric

merited a score of 41. A score of 41 connotes the presence of serious symptoms and

impairments in work and social functioning. Eric’s problems with social functioning reflect the

lack of a steady relationship over the past eight years although he currently worried about not

having a girlfriend.

Differential Diagnosis

Because of the numerous symptoms Eric described during his assessment and the high

rate of comorbidity in bipolar disorder (Leahy, 2007), several differential diagnoses were

considered and subsequently rejected based on the criteria found in the DSM-IV-TR (APA,

2000). Generalized anxiety disorder was considered based on Eric’s description of pacing and

worries but subsequently discarded due to his anxiety outside of his mood disorder lacking

clinically significant impairment.

Additional diagnoses of schizophrenia, schizoaffective disorder, psychotic disorder not

otherwise specified (NOS), and delusional disorder but ruled out because Eric’s delusions and

hallucinations were only present during mood episodes (APA, 2000). Obsessive-compulsive

disorder (OCD) was considered due to Eric’s characterization of his thoughts being persistent

and his trouble discarding old newspapers. This diagnosis was rejected, however, because the

obsessions were related to real-life worries and they both failed to cause significant impairment.
CASE STUDY: ERIC AND BIPOLAR 8

Attention-deficit/hyperactivity disorder (AD/HD) was considered because of Eric’s complaints

of concentration difficulties but ruled out because these periods were better explained by his

BPD I. Major depressive disorder was considered based on Eric’s suicide attempts and the

episode he experienced after quitting his job as a stockbroker. Although major depressive

disorder is commonly misdiagnosed with bipolar disorder, Eric’s experience of more than one

manic/hypomanic episode ruled out the diagnosis (Perlis, 2005). Adjustment disorder was

considered based on Eric’s serious depressive symptoms emerging after his quit his job, but

ruled out because his distress was better explained by his BPD I.

Etiology and Progression of Bipolar Disorder I

Eric’s symptoms of BPD began while he was still in high school when he started

experiencing concentration difficulties, anxiety about getting into college, depressed mood, and

first suicide attempt. While not meeting the threshold for any of the bipolar disorders, these

symptoms are common for adolescents at risk for developing BPD (Moreno et al., 2007; Price &

Marzani-Nissen, 2012). Although Eric continued to be symptomatic he did not experience his

first full-blown manic episode until his freshman year of college. Because Eric’s episode was a

manic episode instead of a hypomanic episode, he met the criteria for BPD I, which requires a

manic episode, from the outset (APA, 2000). This episode can be differentiated from a

hypomanic episode, which would result in a diagnosis of BPD II, a less severe form of BPD, for

several reasons (APA, 2000). These include Eric’s engaging in dangerous and impulsive

behavior including taking several recreational drugs, several fist-fights, and ending with a high

speed car accident and four-day hospitalization. However, most importantly, the key difference

in manic versus hypomanic is the marked impairment in academic functioning (Alloy et al.,

2012; Hatchett, 2010; Leahy, 2007; Nusslock et al., 2012). This was because Eric’s increased
CASE STUDY: ERIC AND BIPOLAR 9

energy was spent painting his dorm room over and over causing him to miss several classes. As

a result, this behavior is more consistent with functional impairment (academic) rather than goal-

directed behavior. Having a manic episode around the age of 18 is considered an early onset and

predictive of a severe course of BPD in general (Alloy et al., 2012; Miller, 2006). Furthermore,

Eric’s comorbid anxiety, demonstrated by his text anxiety and whether he would get into college

also increased his chances of developing BPD I (Bowden et al., 2012). Because the course of

BPD I if variable, an indication of severity is the span of time in which four signs are manifested

during an individual’s lifetime (Miller, 2006). These include: a) manic moods and behaviors; b)

dysphoric and negative affect; c) cognitive impairment (apart from distraction [Williams et al.,

2011]); and d) psychotic episodes (Miller, 2006). Aside from the episode freshman year, Eric

continued to get into fist-fights, get into car accidents because of driving recklessly, and went on

shopping sprees where he spent thousands of his parents’ dollars on books, vitamins, and gifts

for his family. In addition, Eric was also hospitalized three times during certain manic episodes.

Deteriorations in Eric’s behavior were also recognized over the course of his illness marked by

three suicide attempts during the past three years. Eric’s suicide attempts were had a clear intent

of death and considered violent confirming the darkness of his depression (Soloff, Lynch, Kelly,

Malone, & Mann, 2000). Eric reported marked cognitive impairment during episodes which left

him so disorganized that he could no longer read books or even watch television. Finally, Eric

experienced an early onset of psychotic episodes only one year after college after he quit his first

job as a stockbroker. After resigning due to fear of failing due to stress, Eric experienced a

prolonged depression episode during which time he began having paranoid delusions. These

delusions were based on the belief that he was being tracked by the CIA and being set up to fail.

Despite being placed on antipsychotics, when Eric did not take them due to adverse side effects,
CASE STUDY: ERIC AND BIPOLAR 10

his delusions began including auditory hallucinations where he believed the CIA was telling him

to take his medications. In addition to the side effects, these psychotic episodes only added to

his noncompliance with his prescription regiment.

Another important predictor of a more severe course of BPD is related to an individual’s

psychosocial environment (Leahy, 2007; Miklowitz, 2008). In Eric’s case, although his parents

allowed Eric to move in with them, paid for his health insurance, and financially supported him,

their behavior probably added to his disease burden. For example, because of Eric’s spending,

his father took away his credit cards and put him on an allowance which left Eric feeling like a

child and became a source of contention between them. In order to avoid further conflict, Eric’s

father stopped telling him he could not use the family car but instead began disconnecting wires

so that the car would not start. This probably added to Eric’s delusions that the CIA’s

interference that he was being set up to fail because without a car he would not be able to get to

work or go on job interviews. While these delusions were clearly psychotic, one of the worries

he expressed during the assessment was his fear the car would break down, a fear that his

father’s behavior was likely contributing to his psychosis. Another factor was his parents

fighting about his treatment which often resulted in a tense and hostile environment, which is

believed to be stressor that can either trigger or exacerbate BPD episodes (Bowden et al., 2012).

In summary, over the past 15 years Eric’s BPD had severely impacted his life by interfering with

his autonomy by leaving him unable to become financially independent, without a girlfriend,

cognitively impaired, and suicidal. Without a new treatment plan, if Eric’s course continued in

this vein, his chance of eventually completing suicide was very high. Bipolar disorder is

associated with the highest rate of suicide with one out of three individuals committing suicide

(Leahy, 2007).
CASE STUDY: ERIC AND BIPOLAR 11

Biopsychosocial Theory of Bipolar Disorder

Prior to developing a treatment plan for Eric, it is important to understand the

mechanisms of disorder. While an exact neurobiological cause has yet to be discovered, I

believe the best theory advanced to date is the behavioral approach system (BAS) dysregulation

theory. The BAS dysregulation theory is based on the belief that individuals with BPD have

polarity specific triggers and the onset of episodes (Urosević et al., 2008). The BAS is

responsible for creating motivation incentives for an individual to act in the presence of reward

or punishment cues (Nusslock, Abramson, Harmon-Jones, Alloy, & Hogan, 2007). Individuals

who cannot effectively regulate their BAS are prone to hypersensitivity to triggers of BAS-

relevant events or cues (Urosević et al., 2008). BAS hypersensitivity is a trait that is believed to

be hereditary. Presence of the trait is necessary but not sufficient for development of BPD.

Instead, the psychosocial environment triggers the onset of symptoms and course of the disease

(Urosević et al., 2008). Factors that influence BAS hypersensitivity and dysfunction are

cognitive styles related to high levels of perfectionism, goal-striving, and autonomy (Urosević et

al., 2008). Autonomy in the BAS is considered the value placed on achievement, social

mobility, and independence (Alloy et al., 2009).

The mechanisms through which the BAS dysregulation theory causes manic or

depressive episodes depend on two major factors including whether a situation is considered

BAS-relevant and the perceived efficacy with which the individual perceives their ability is to

affect the outcome (Urosević et al., 2008). Situations that are relevant generally involve some

the opportunity to satisfy some biological or social need to improve an individual’s life, such as a

job or girl/boyfriend. For example, in relation to this theory Eric’s stress about getting into

college would be considered a BAS-relevant event because it represents an opportunity to

achieve a goal or reward (Alloy et al., 2009; Nusslock et al., 2007; Urosević et al., 2008). Eric’s

belief that his school work was integral in his chance of achieving this goal resulted in extreme

activation of the BAS because of his innate hypersensitivity and the onset of his first manic

episode (Urosević et al., 2008).

Conversely, BAS deactivation occurs when an event that is BAS relevant occurs in the

context of an individual’s inability to affect the outcome or after the loss of a BAS relevant

event/cue (Urosević et al., 2008). For Eric his cognitive style of perfectionism may have left him

feeling as if he would not be able to succeed in this field. As a result, he resigned and lost out on

a previously earned reward. Because this represented a BAS relevant event with low efficacy the

result was an extreme deactivation of the BAS which triggered the onset of a depressive episode

(Urosević et al., 2008).

The BAS theory also proposes the individual’s value places on the event will also predict

the magnitude and duration of the ensuing episode (Urosević et al., 2008). During the

assessment, Eric reported that he was hired one year after college. An inference of his getting a

job after searching for an entire year probably added to the value Eric placed on achieving this

particular goal. The loss of something so valued due to his belief that he was a failure and would

be unable to handle the stress ran opposite of his cognitive-style and is probably why this

particular episode was significant for its duration and severity in so far that it marks the onset of

his psychosis. However, the BAS also proposes that treatment targeting these response-styles

may be able to reduce the hypersensitivity to the event and thereby reduce the activation or

deactivation of the BAS. In other words, if Eric’s cognitive styles were restructured to reduce

the value placed on BAS-related events, he may be able to influence the severity of the episode

or eventually prevent it altogether (Bowden et al., 2012; Miklowitz, 2008).

Bipolar Disorder Treatment

Standard treatment of BPD involves pharmacotherapy and continued care, which consists

of medication management and occasional psychotherapy (Miklowitz, 2008; Williams et al.,

2011). Unfortunately, medications generally have a ceiling effect (Miklowitz, 2008). This has

two indications. The first is that medications should be evaluated over time and switched as

needed according to the individual’s episodes and symptoms (Williams et al., 2011). In addition,

the identification of psychosocial triggers and their association with mood episodes suggested the

development of therapy to diminish these effects to improve the course of BPD episodes

(Bowden et al., 2012; Urosević et al., 2008). Accordingly, several studies were conducted and

demonstrated intensive psychosocial therapy combined with more proactive medication

management was significantly more effective than standard care (Miklowitz, 2008).

Three types of therapy, psychoeducation, family focused therapy, and cognitive

behavioral therapy, have been identified as beneficial to individuals with BPD by resulting in

shorter duration of episodes, longer remissions, and better mood even during an acute episode

(Bowden et al., 2012; Miklowitz, 2008). In addition, these therapies were associated with

increased overall functioning, reduction in cognitive impairments, and higher recovery rates

(Bowden et al., 2012). Psychoeducation involves elements including educational sessions,

recognizing prodromal symptoms of an episode, developing relapse prevention plans, and

implementing management strategies, such as regulation of sleep and activity regulation

(Miklowitz, 2008). This type of therapy, however, was found to be more successful at

preventing and managing manic episodes versus depressive episodes (Miklowitz, 2008).

Miklowitz believed the therapy’s focus on treatment compliance, early identification of triggers

and manic symptoms, and coping skills such as getting more sleep and decreasing goal-related
CASE STUDY: ERIC AND BIPOLAR 14

activity were the mechanisms responsible for the successful outcomes. Family focused therapy

uses a behavioral approach by promoting emotional reactivity strategies and enhancing

communication with family/caregivers to prevent or work through conflict and learning to ask

for help (Miklowitz, 2008). Conversely, this therapy was shown to be more effective at

preventing and managing depressive episodes (Miklowitz, 2008). Miklowitz thought these

effects were due to individuals assigned to this treatment generally being from high expressed

emotion and family conflict environments and the therapy’s focus on problem-solving and

communication skills as opposed to symptoms identification. Cognitive behavioral therapy

involves cognitive restructuring and increasing treatment adherence. Miklowitz found that

research was mixed on the efficacy of this therapy, which he believed was probably due to

inconsistent elements included during trials. Overall, the consensus appears to be that treatment

should be based on the current state of the individual, their last/current episode, symptom

recognition, relapse prevention, and strict treatment adherence (Miklowitz, 2008; Miller, 2006).

Based on this evidence, I would recommend Eric undergo an intensive course of psychosocial

therapy including elements focusing on education, acceptance, adherence, cognitive restructuring

about dysfunctional attitudes about his feelings of failure, relapse prevention, communication

strategies, and symptoms management. Furthermore, I would require his parents, especially his

father undergo a few sessions of psychoeducation focusing on learning about the disease, its

course, and the importance of treatment compliance. Moreover, I would have the therapist stress

treatment noncompliance has been shown to result in a loss of 14 years of life in terms of

functional impairment and 9 years based on suicide attempts and completed suicide (Miller,

2006). Furthermore, I would have Eric’s medication re-evaluated to eliminate as many adverse

effects as possible and potentially changed based on improvements due to therapy.

DSM-5 Changes and Implications

One of the major changes to the DSM-5 for bipolar disorder includes the use of increased

energy as an additional criterion for diagnosing mania or hypomanic (APA, 2012). While at first

glance this seems like a useless addition, considering the difficulty in distinguishing hypomanic

from mania, when considered in terms of distinguishing BPD from major depressive disorder,

this change makes much more sense (Perlis, 2005). For example, one of the major reasons for

misdiagnosis is because an individual usually seeks treatment when feeling depressed and

without any evidence of mania of any degree there is no reliable method to distinguish bipolar

depression from unipolar depression (APA, 2012; Hatchett, 2010; Perlis, 2005). This is a serious

problem because medications used to treat unipolar depression are generally unsuccessful for

individuals with BPD (APA, 2012; Perlis, 2005). Because the misdiagnosis between depression

disorders has more potential for harm than the hypomanic versus manic episode problem, I

believe that the current plans for the DSM-5 revisions are warranted.
CASE STUDY: ERIC AND BIPOLAR 16

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