HISTORY OF PRESENT ILLNESS
Miss. Ann is a 30-year-old white woman with symptoms chronic depression and mania. The most apparent sign is her total withdrawal from life, and she is always putting on a distraught look. For the past week that Miss Ann has become for sessions, she will always look optimistic and enthusiastic at the beginning of the sessions but quickly withdraws, becomes distant and hardly communicate back to the physician. Today she is accompanied by her teenage son who is obviously too worried for his mum.
” We don’t know what to do anymore, one time she is happy and doing chores all over the house, then something minor happens, and she gets soo angry. Is mum okay?” The teary boy asks. Miss Ann, however, thinks her son is exaggerating. ” Don’t worry about my kids they are just teenagers, what do they know about life. But they are good kids, they mean well” She says.. Miss. Ann thinks that her kids are spoilt because she has always given them everything they want.
Miss. Ann was recently diagnosed with bipolar disorder, but for the past last year she has not accepted her situation. She simply thinks her situation has been blown out of proportion. In the one year, she has been coming in for sessions; her condition has been worsening. Besides the fact that she does not adhere to the medication given or even misses most of her sessions has made it even harder for her to improve. Her eldest son confesses that the environment at home has become tensed since no one knows when she might get angry. He further states that she often breaks utensils and hits the wall whenever she gets outraged and thinks that all her kids are asleep.
The most recent episode happened in the hospital. She had arrived late as usual for her sessions and was in the company of another patient. The two had seemed to be having a wonderful conversation, and she occasionally smiled and even managed to laugh. However for some reason Miss. Ann became too aggressive and started raising her voice at her companion. The patient tried telling her to come down, but that only fueled her anger, even more. Several nurses went in and saved the situation. Afterwards, the patient was asked what happened to upset Miss. Ann. The patient was honestly clueless. When asked about what their conversion was about, she revealed they were talking about challenges single women face. Sadly, she subconsciously indicated that black single women had a tougher time raising their families. Apparently, this was the issue that upset Miss. Ann as she felt that her struggles were being belittled.
PAST PSYCHIATRIC HISTORY
According to Miss. Ann close friend Julia, Ann was cheerful and vibrant as a young adult from 20 to around 25. Like most youth, she believed she would fulfil her dreams. Julia suggests that Miss. Ann problems had started soon after she got married since it around that time that she started noticing some changes. True to her words there are record proving that Miss. Ann started undergoing counselling sessions around 2years after her marriage. The counselling sessions helped for a while but when at age 28 she was diagnosed with serious depression. Her Son confesses that it was at that time, that his mum started showing deviation in her moods although it would happen occasionally. When asked about that time Miss Ann defends herself that it is normal to feel low once in a while.
Social History
Miss. Julia, Ann’s closest friend, mentions that Ann was a very cheerful girl as a child since they have been friends since childhood. Miss. Ann biological parents are both alive only that she had detached from them since they opposed her marriage to Ex-husband. Every member of her family are well schooled, and her father is a well-known businessman. She has one sibling who is a boy on campus known for wild living and love for adventure. He is therefore hardly at home. Ann was very friendly before being with depression. Julia affirms that apart from herself, Ann has cut off all communication with their friends. Miss Ann son adds that his mum is very hardworking and has managed to run three business as well as take care of them. Ann has two sons and a five-year-old daughter who are all adopted. Julia affirms that Miss. Ann loves her children.
Family history
There is no record of bipolar, extreme anxiety or extreme depression in Ann’s family. However, Ann’s dad is known to be very firm and too aggressive and more so with his family. Ann’s mother is reserved and laid back as compared to her children and husband. Ann’s grandparent are still alive but quite old. They, unlike their son, were not that wealthy but an average family. They are proud of their son although Miss. Ann confesses that she believes they too fear their son. Miss. Ann divorced from her marriage around three years after her marriage, and she insists she does not regret it. If given a chance would still do it again.
The Father of Miss Ann occasionally drinks but not to the extent to be considered an issue. He is known to be strict and while as children Miss Ann and his brother did everything he commanded them to. However, they changed growing up. Ann’s father has no sibling, and she does not know any relation from her mother’s side. Miss Ann believes that their separation from her mother’s side is due to her father. Miss Ann’s family have never been to see her or accompany her in any of her session starting from when she was diagnosed with depression. Similarly, her children have never seen their grandparent but occasionally talk to their grandmother on the phone.
Personal Medical History
Miss Ann has a history of depression which she has never really overcome aside from bipolar disorder. Moreover, she also has a long record of hypotension which has occasionally led to her fainting both at work and home. She frequently suffers from chronic insomnia and at such times needs the help of pills to get her to sleep. Miss Ann is often fatigue from her busy schedule which is a contributing factor to the fainting episodes. In the past one year, Miss Ann has become very irritable and easily prone to violence. She has fired more people in the past one year compared to the rest of the years. She has several bruises on her hand from cuts she gets after breaking utensils and hitting walls. Miss Ann has lost her appetite for the past one year, and she admits she finds nothing to be sweet but only eats to survive. She has never had any surgery, has no broken bones despite having the several bruises. Moreover, she has no record of suicide attempts despite how depressed she gets.
Current Medication
- Lithobid a mood stabilizer
- Seroquel an Antipsychotics
- Lexapro an Escitalopram antidepressant
- Benzodiazepines
- Allergies
Miss Ann has no Allergies, and there are no medical records on any allergy.
Review of Systems
General: Miss Ann has lost 2 in the over the past one week and the son says it because she has hard;y ate anything in the past one week.
HEENT: Admits to having headaches. Describes vision as weak and that blurred vision and visual problems other than when trying to read.
Peripheral Vascular: Denies peripheral numbness, paresthesia’s, and coldness of extremities. She Denies intermittent swelling, claudicating, cramps, varicose veins, or thrombophlebitis.
Hematologic: Denies bruising or bleeding. No record of a history of blood transfusions.
Urinary: Positive for polyuria and Nocturia. Denies any dysuria, hematuria, urgency, hesitancy, incontinence, infections, or stones.
Physical Examination
General: Miss Ann is 5 feet 0 inches 80 pounds BMI 29.6.
Vital signs: Blood pressure 146/70, heart rate 80, and respiratory rate 20.
MENTAL STATUS AND ASSESSMENT
Miss Ann is a thirty-year-old woman who currently looks younger than her age because she has become emaciated in the past one year due to lack of appetite and overworking. It will be noticed that she has become very impatient and has developed zero tolerance for mistakes. The zero tolerance results from irritability which is as a result of inadequate sleep. Her son confirms that his mum hardly sleeps since she goes to bed late and wakes extremely early. This increases her level of fatigue. Miss Ann needs to be always doing something and cannot stay still if not involved in an activity. Even during Sessions she will insist to either watch updates of her trades or be knitting but never to simply sit and talk. The need arises as a mechanism of fighting low moods. As a result, she tries to engage herself so that she can maintain her happy state (Grunze, Vieta, Goodwin, Bowden, Licht, R, Azorin, 2018). Ann admits that she feels happier when engaging in activity rather than staying idle or sleeping. When happy she depicts too much excitement. At such times she becomes over expectant to improve her condition as well as in her various areas of life. However, anything small can spoil her entire moods.
Moreover, Miss Ann in the past one month shows an extreme withdrawal in life and more so after being forced by her friend, Julia, to put a stop to her business and attended to her health. The depression she is falling into is a mere shadow of the real problem. Subconsciously her mind prefers to fall into the state of despair and numbness than accept and face the real issue in her life. To patients like Ann, it is important to do a background check on the patient as well as family to identify if there any cases of any psychiatric conditions in the family no matter how lean they are (Whitton, Treadway& Pizzagalli,2015). The fact that her condition worsened from being depressed to being bipolar and depressed portrays that her current manic state is not just as a result of hormonal imbalance but stems deep from conditions that have been treated.
Laboratory Data
Miss Ann has some records which she did on the onset of the Bipolar disorder. The test did then was to check for hormonal imbalance. She took a blood test, and the test revealed that her thyroid, estrogen, testosterone, and cortisol levels were normal. She also underwent pelvic exams, and there was no presence of any unusual lumps or tumours. Lastly, she took a thyroid scan, but no abnormalities were recorded. Miss Ann hormonal level was found to be 19 mlU/ml), a figure that falls within the normal range.
Examining laboratory results is mandatory when dealing with bipolar cases. It is important to eliminate any chances of hormonal imbalances to avoid misdiagnosis. The necessity is as a result of many instances where patients have been termed Bipolar and taken through series of treatment yet the only problem was hormonal imbalances. In such a case it only requires correct medication to stabilise the imbalances. Afterwards, such patients can return to their normal lives.
Psychiatric Summary
Miss Ann’s bipolar condition is a result of unfaced fears and anger towards her parents. Her major undoing is an intense fear of being seen as weak or vulnerable. She has always worked hard in school and was termed as a brilliant and vibrant student. But behind the vibrant nature is a fear of weakness and not necessarily a failure. She associated success in academics and progress in all areas of her life to strength. She, however, is not afraid of failure that rather such situation provides an environment for her to become better and more successfully. This can be seen in the way she believes the divorce caused no harm to her because she is better off by herself than with someone who does not care about her. She insists that she does not need a man to stand on her feet and has worked hard to have three successful business which still runs and make a profit even when off work like now as she goes through treatment.
Her fear of weakness results from her resentment from her mother who she perceives to be weak. According to Miss Ann, her mother has a significant fear of her father, and she does as he says. While growing up, Ann decided she will never be anything like her mother. Besides, her anger towards her father has impaired how she views men generally and has made her hate any ideology that suggests women need men in any way. Her anger became worse when the dad did not approve of her ex-husband and as such Ann vowed to marry the guy at all cost just to prove her dad wrong.
Unfortunately, the marriage did not work and Ann in her fear to admit failure to her parents, adopted the idea that she could still win minus the husband. In her efforts not appear weak, she adopted three kids, started her business and seemed to live a successful life despite the divorce. She went through grief or healing from the separation. Being able to provide a good life for her children as well as her business becoming successful she felt strong enough to face her parents and show to her mum that woman can stand on her own and show to her dad, that she turned out better than he had thought. However, the divorce did affect her because she complains of feeling empty from time to time since her divorce. The habit of blocking pain through a tough and successful countenance is what has led to the progression of her mood shifts because she has reached limits of suppressing her pain. The unresolved issue with her parents is majorly what is causing her not to deal with her marital problems. In the end, Miss Ann has subconsciously piled pain upon pain and cover that with hard work. However, she is only but human, and her strength to bear pain has reached limits and must be walked through healing process which will eventually pave the way for the Bipolar disorder to be dealt with.
Plan
Safety
The first step is to convince and have Miss Ann Friend, Miss Julia, To temporarily move in within with Ann so that she can help prevent her from harming herself or even the children. According to Vancampfort, Stubbs, Mitchell, De Hert, Wampers, Ward, & Correll (2015) Patients with extreme mood changes can do something in a spun of the moment that can endanger the lives of others without meaning to or even remember how it happened. Miss Julia can help by ensuring glass-like object are not easily found and can be a good support system for the children who need as much emotional support as they can get.
Therapy
Therapy is essential for Ann because it is the roots of all her problems. She will start with Cognitive behavioural therapy (CBT) which will help her resolve her anger and resentment to her parents(Mertens, Wang, Kim, Diana, Pham, Yang, & Eames, 2015). Moreover, she will undergo Interpersonal and social rhythm therapy (IPSRT) which will help greatly in her eating and sleeping habits. Lastly, she will be taken through family therapy alongside her children and Julia who at the moment are her support system.
Education
Miss Ann will have to be educated on her condition of bipolar, what it is, why she developed it and how to overcome it. Knowing one’s condition is a major help to recovering since one knows what to expect and can plan on time on what to do when episodes happen (Grunze, 2015). This makes the patient feel more in charge of their situation and has helped them to manage their condition better.
Medication
Bipolar disorder varies from one person to another; no specific medication can be termed as best. However, Miss Ann will continue with the medication we are currently going her as stated above in current medication. In the event, they don’t produce significant change, or she reacts to them it will be changed accordingly.
Monitoring
Correll, Detraux, De Lepeleire, & De Hert, (2015) argue that Bipolar cases must monitor at least on a monthly bases to a certain if the prescribed medication and method of treatment is working and especially because it deals with patients emotional state. Therefore Miss Ann will be under monthly assessment to a certain how well she manages her mood change, how far she has gone with facing her fears and if there is any change in her sleeping eating and her interaction with the society.
References
Correll, C. U., Detraux, J., De Lepeleire, J., & De Hert, M. (2015). Effects of antipsychotics, antidepressants and mood stabilisers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder. World Psychiatry, 14(2), 119-136.
Grunze, H. (2015). Bipolar disorder. In Neurobiology of Brain Disorders (pp. 655-673).
Grunze, H., Vieta, E., Goodwin, G. M., Bowden, C., Licht, R. W., Azorin, J. M., … & Members of the WFSBP Task Force on Bipolar Affective Disorders Working on this topic. (2018). The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Acute and long-term treatment of mixed states in bipolar disorder. The World Journal of Biological Psychiatry, 19(1), 2-58.
Mertens, J., Wang, Q. W., Kim, Y., Diana, X. Y., Pham, S., Yang, B., … & Eames, T. (2015). Differential responses to lithium in hyperexcitable neurons from patients with bipolar disorder. Nature, 527(7576), 95.
Power, R. A., Steinberg, S., Bjornsdottir, G., Rietveld, C. A., Abdellaoui, A., Rivard, M. M., … &Cesarini, D. (2015). Polygenic risk scores for schizophrenia and bipolar disorder predict creativity. Nature Neuroscience, 18(7), 953-955.
Vancampfort, D., Stubbs, B., Mitchell, A. J., De Hert, M., Wampers, M., Ward, P. B., … & Correll, C. U. (2015). Risk of metabolic syndrome and its components in people with schizophrenia and related psychotic disorders, bipolar disorder and major depressive disorder: a systematic review and meta‐analysis. World Psychiatry, 14(3), 339-347.
Whitton, A. E., Treadway, M. T., & Pizzagalli, D. A. (2015). Reward processing dysfunction in major depression, bipolar disorder and schizophrenia. Current opinion in psychiatry, 28(1), 7.
