Manic Depressive / Bipolar Disorder in an Adult Woman
“In these stories, the identities and locations have been changed to ensure client confidentiality.”
A 29-year old married, mother of a young child age 2, presented with a history of recurrent and disabling depression and headaches. Several weeks prior to presentation, she became severely depressed and had difficulty moving, had diminished appetite, had crying spells much of the day and felt suicidal. At the time she presented, she was on Prozac 20 mg a day, and described herself as getting “manicky” on the Prozac. By this, she meant that she was “rushing around, laughing a lot and having more anxiety.” A past trial with Wellbutrin was poorly tolerated because of sweating episodes, insomnia and agitation. Her depression was worsening despite the Prozac treatment.
Family history revealed severe mood swings in both her father and paternal grandmother. Grandmother at times would take to bed for long spells, and she had been hospitalized for “unknown reasons” that the family refused to talk about, and the client recalled that the secrecy was because of something “shameful” about her grandmother’s condition and behavior.
Because of the suggestion of Manic Depressive / Bipolar Disorder by personal and family history, she was placed on Seroquel 100 mg at bedtime. Within one week’s time, she began to improve markedly, including clearer thinking, more productive work being done, less depression and more energy. Within five weeks after the institution of Seroquel, the client was feeling “terrific.”
She was seen in supportive psychotherapy and provided advice on parenting her two year old daughter, which helped to settle down the child’s behavior and gave the client more confidence and a feeling of control over her life.
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There was a past history of concussion at age 18, when she suffered loss of consciousness. She also described a history of mood swings for many years. There was also a history of alcohol abuse when she was a teenager. The diagnosis of major depressive disorder was suspect, given the poor response to both antidepressants. Prozac was discontinued because it appeared to be worsening the underlying mood swings.
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by Tabetha Cooper
The field of psychology deals with many mental disabilities. This paper is going to examine the case of Susie, who suffers from bipolar disorder. It will discuss the biological aspects of the disorder, including any brain abnormalities that have been implicated in the disorder, genetics or familial traits, and the influence of neurotransmitters and brain chemistry. Additionally, it will explore the types of medical approaches that are used in treating bipolar disorder.
Susie is a 20-year-old sophomore at a small Midwestern college. For the past five days she has gone without any sleep whatsoever and she has spent this time in a heightened state of activity which she herself describes as “out of control.” For the most part, her behavior is characterized by strange and grandiose ideas that often take on a mystical or sexual tone. For example, she recently proclaimed to a group of friends that she did not menstruate because she was a “of a third sex, a gender above the human sexes.” When her friends questioned her on this, she explained that she is a “superwoman” who can avoid human sexuality and still give birth. That is, she is a woman who does not require sex to fulfill her place on earth.
Some of Susie’s bizarre thinking centers on the political, such as believing that she had somehow switched souls with the senior senator from her state. From what she believed were his thoughts and memories, she developed six theories of government that would allow her to single-handedly save the world from nuclear destruction. She went around campus, explaining these theories to friends and even to her professors and began to campaign for an elected position in the U.S. government (even though no elections were scheduled at the time). She feels that her recent experiences with switching souls with the senator would make her particularly well suited for a high position in government; perhaps even the presidency.
Susie often worries that she will forget some of her thoughts and has begun writing notes to herself everywhere; in her notebooks, on her computer---even on the walls of her dormitory. Susie’s family and friends, who have always known her to be extremely tidy and organized, have been shocked to find her room in total disarray with frantic and incoherent messages written all over the walls and furniture. These messages reflect her disorganized, grandiose thinking about spiritual and sexual themes.
Susie has experienced two previous episodes of wild and bizarre behavior similar to what she is experiencing now; both alternated with periods of intense depression. When she was in the depressed state, she could not bring herself to attend classes or any campus activities; she suffered from insomnia, poor appetite, and difficulty concentrating. At the lowest points of the depressive side of her disorder, Susie contemplated suicide.
Some background information; Susie grew up on what she terms a “traditional Irish home” with overprotective and demanding parents. Of the five children in her family, she was the one who always obeyed her parents and played the role of the good girl of the family, a role she describes as being “Little Miss Perfect.” Susie describes herself as being quite dependent on her parents, who treated her as if she were much younger than she actually was. In contrast to their passive obedience, Susie describes her siblings as rebellious. For example, her older sister told her parents that she was sexually active in high school.
Susie describes her parents as exceptionally strict with respect to sexual matters; they never discussed issues related to sex except to make it clear that their children were to remain virgins until they were married. Throughout high school, Susie’s mother forbade her to wear makeup. She remembers being shocked and frightened when she began menstruating; she was very distressed at the loss of control that this entailed. Susie never dated in high school and has never had a steady boyfriend.
Susie’s family history shows evidence of mood disorders; her maternal grandfather received electroconvulsive therapy (ECT) for depression and her father’s aunt was diagnosed with depression when she went through menopause.
The first step is to determine what form of bipolar that Susie is suffering from so that she can receive the proper treatment. The National Institute of Mental Health (NIMH) lists the four types of bipolar disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). These four types are bipolar I, bipolar II, bipolar not otherwise specified (BP-NOS), and cyclothymic disorder. Bipolar one includes symptoms of extreme mania, intense depression, or a mixture of the two that lasts a minimum of seven days. An acute bout of mania that requires immediate treatment in a hospital or mental health institution is another way to help a psychologist determine that the patient should be categorized as bipolar I. This mania or depression must be behavior that deviates from the person’s normal behavior (NIMH, 2008). Something worth noting is that these episodes of mania and depression have been associated with mild or severe psychotic episodes (Appalachian State University, n.d). Bipolar II is usually diagnosed when a person switches back and forth between mildly manic (also referred to hypomania) and depressive episodes. In the bipolar II type there are not any mixed episodes nor does the person go into an extreme mania state. BP-NOS is considered when a person is displaying behavior out of the realm of what is normal for them but that does not meet the all of the symptoms of either bipolar I or II. Cyclothymic disorder is merely a moderate form of bipolar that includes symptoms of hypomania and depression which switch back and forth over a period of two years or more, but not to the extremes that would place them in category I, II, or not otherwise specified. (NIMH, 2008).
Susie is clearly displaying symptoms of bipolar I disorder. She believes that she is a “superwoman” who does not need a male to help her reproduce, therefore having no need for menstruation. She also believes that she was able to switch souls with a senator making her more than eligible for a position within the U.S. government. Finally, she is campaigning for an election that is not even taking place at the time. This all points to psychotic episodes, which is a symptom only present in the bipolar I category. She is displaying mania by writing all over her things and making notes to herself on her computer. In addition, she has deviated from her natural behavior which is evident through her disorganization. This is not Susie’s first episode of mania and in the past her mania was followed by a deep depression that even led her to suicidal thoughts.
Studies show that there is a clear link between genetics and bipolar disorder but have been unable to identify exactly what the abnormality is. There have been numerous studies on monozygotic (MZ) twins, first generation relatives (i.e. mothers, fathers, sisters, and brothers), and unrelated people. All studies dealing with family and those who suffer from a bipolar disorder show that the closer the genetic ties the more prevalent bipolar is in those studied. The chances of two people selected at random to have a propensity of bipolar is around only 1 percent, first generation relatives show about a 10 percent chance, and it is about 60% more likely for both monozygotic twins to develop bipolar disorder (Caddock & Jones, 1999). This rate of 60 percent is the highest known rate between those related to share the same genetic disorder (Durand & Barlow, 2007). There have also been links to family members who have other disorders such as manic depression and obsessive-compulsive disorder (NIMH, 2008).
There have been many studies regarding what specific genetic dysfunction could cause people who are closely related to suffer from the same illness. Different studies have found links between various chromosomal abnormalities in related individuals. Several chromosomes in different studies have proven to be the culprit but no test has been able to be duplicated, which needs to occur before a definite link can be established. More recent studies have made use of DNA and the placement of markers to find a link but none have had successful duplicated results as of yet (Caddock & Jones, 1999).
In Susie’s case, as far as we know she is not a twin and none of her first generation relatives have bipolar disorder. However, she does have relatives on both the maternal and paternal sides of her family that have been treated for depression. The relatives were both second generation relatives (i.e. grandparent, aunt, uncle). The age at which her family members were diagnosed with depression is unclear, although it can be assumed that since it was during menopause that her aunt was in the later stages of her life. Susie is only twenty, so the genetic ties are not as clear in this case, but they do exist.
McLean hospital is associated with Harvard University. They dedicate a lot of time on researching brain abnormalities in people with bipolar disorder and schizophrenia. Their research team has found that during sleep there are many similar brain patterns in people who suffer from bipolar disorder and those who do not. They have also discovered that there are slight differences as well and are dedicated to discovering the cause of these. The McLean research team has found powerful differences in “default mode special extent” between their test subjects with bipolar disorder and their control group. These differences have been found during analysis of the whole brain on single patients discovered on “parasagittal, cornal, and axial slices” of the brain (McLean Hospital, 2011).
As Susie’s psychologist, I would strongly suggest that she participate with the McLean hospitals for these studies while she is in the mania stage of the bipolar. I think that the best result in the study of brain abnormalities could come from studies done on a person exhibiting psychotic episodes. This could potentially lead to a breakthrough in the study of brain abnormalities in bipolar patients and even find a way to treat Susie’s symptoms quickly.
It has been thought that the etiology of mood disorders such as bipolar disorder is the result of malfunctions in the neurotransmitters. If this were to be the case then the most likely candidates for problems are the norepinephrine (NE), serotonine (5-HT), dopamine, and gamma-aminobutyric acid (GABA) neurotransmitters. Generally, NE, 5-HT, and dopamine have been fingered in single cause models of theory. Most recently, GABA has been hypothesized to be part of multi-causal neurotransmitter theories (Appalachian State University, n.d.).
Norepinephrine (NE) is responsible for a person’s anxiety, arousal, and memory. In early studies it was thought that a deficit of NE would cause depression whereas a surplus could be contributed to manic episodes. Serotonine (5-HT) is accountable for a person’s sexual desire, sleeping patterns, moods, appetite, and activity. A lack of 5-HT can cause a person be more apt for mood disorders such as bipolar disorder. Dopamine is attributed to thought processes, body movements, and levels of hormones. Studies have shown that escalated dopamine neurotransmitters are responsible for the psychotic episodes associated with mania and that a deficiency of dopamine can cause depression. However, dopamine does not account for mania that doesn’t include psychotic episodes (Appalachian State University, n.d.). Gamma-aminobutyric acid (GABA) is a neurotransmitter that inhibits synaptic communication between neurons (Durand & Barlow, 1999). Low levels of GABA have been linked to both depression and mania, suggesting that GABA is needed for necessary neurotransmitters such as NE, 5-HT, and dopamine to be distributed to neurons successfully (Appalachian State University, n.d.)
In a single model theory, Susie might suffer from an increase in dopamine since her symptoms include mania in conjunction with psychotic episodes. However, in the multi-neurotransmitter theory, the problem can be explained with several different neurotransmitters and as a result of low GABA levels. As her psychologist, it would be wise to suggest that she have blood tests taken to see if she is suffering from increased or decreased levels of any of these neurotransmitters so that the proper medication can be prescribed to her.
Bipolar disorder is a life altering illness. It is not curable and those who suffer from it will suffer mania and depression several times throughout their lives. The best course of action for treatment is a proper medication and psychotherapy. These treatments are needed for a person with bipolar disorder from the time they are diagnosed throughout the remainder of their life. Mood stabilizing medications are the best course of action and include lithium (treats mania), depakote (treats mania), lamictal (for maintenance of the symptoms of bipolar disorder), and neurontin, topamax, and trileptal (all are anticonvulsant medications) (NIMH, 2008).
Antipsychotic medications are also sometimes prescribed to treat bipolar disorder, although they are usually prescribed in conjunction of other medications. Olanzapine and Aripiprazole are often prescribed together with an antidepressant to help relieve symptoms of severe mania, psychosis, or a mixed episode (NIMH, 2008). Seroquel is used to treat the symptoms of sudden manic episodes and became the first antipsychotic to receive FDA approval for treating bipolar depressive episodes in 2006 (NIMH, 2008).
Antidepressants such as Prozac, Paxil, Zoloft, and Wellbutrin are often prescribed to treat the symptoms of depression which occur those with bipolar disorder. Patients who take these antidepressants usually take a mood stabilizer, as well, which works to prevent the risk of switching to mania or hypomania or of developing symptoms which cycle rapidly (NIMH, 2008).
As a psychologist and taking into account Susie’s diagnosis of Bipolar I, her family history, and the seriousness of her symptoms, I would recommend a three-pronged approach to treating her disorder. I believe that regular psychotherapy in combination with an antipsychotic such as Seroquel and a mood-stabilizer such as Lithium may make up an effective treatment. I would not start her on an antidepressant as a recent large-scale study has shown that for many people adding antidepressants to mood-stabilizers is no more effective than treating with only the mood-stabilizer (NIMH, 2008). If, after some time, Susie does not respond satisfactorily to the regiment, an antidepressant such as Prozac can be added to the mix.
As Susie’s case has demonstrated, bipolar disorder can affect a person’s mood and cause changes in their behavior. These ups and downs can be very distracting and counterproductive to living a normal life. Many believe that bipolar disorder is over-diagnosed and is often used as a catch-all diagnosis for people with mood disorders. While this may be true, it is also true that many people do suffer from true bipolar disorder and many of those are undiagnosed and untreated. While there is no cure for the disorder, thorough investigation of the patient’s symptoms and family history along with proper treatment, including psychotherapy and prescription medications, can lead to successful management of manic and depressive episodes and the ability for the patient to live a normal life. As with most other psychological disorders, there is much to learn about the causes and most effective methods of treating bipolar disorder. However, research continues and the treatments for the disorder are continually being refined.
Appalachian State University. (n.d.). Diagnostic Criteria: Bipolar I Disorder. Retrieved from: http://www1.appstate.edu/~hillrw/BipolarNeuro/BiPolar/pages/type1.html
Appalachian State University. (n.d.). Neurochemical Causal Model. Retrieved from: http://www1.appstate.edu/~hillrw/BipolarNeuro/BiPolar/pages/neuropathology.html
Caddock, N., & Jones, I. (1999). Genetics of bipolar disorder. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1762980/pdf/v036p00585.pdf
Durand & Barlow. (2007). Essentials of abnormal psychology. Cengage Learning. Mason, Ohio.
McLean Hospital. (2011). Clinical unit base research: schizophrenia and biplar disorder program. Retrieved from: http://www.mclean.harvard.edu/research/clinicalunit/sbdp.php
National Institute of Mental Health. (2008). Bipolar Disorder. Retrieved from: http://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml