Diagnosis and Treatment Considerations for Bipolar Disorder

A Case History: Diagnosing and Treating Carol

In examining the case history of the fictitious client Carol—as she is described to the reader in Daley and Moss’ (2006) text—the counseling student quickly discovers a very troubled individual struggling with what outwardly appears to be bipolar disorder. One can effectively base such a determination on the fact that Carol meets virtually all of the conditions that are required to develop such a diagnosis: (1) She has been involved in intense personal relationships (with both men and women) where idealization and devaluation have each been central to actual outcomes; (2) She demonstrates a significant lack of impulse control (which is typically a means Carol employs to combat loneliness or feeling unwanted); (3) She is severely unstable in her overall affect and demonstrates a lack of control over her angry emotions (drunkenly confronting her parents at inopportune moments and demonstrating an inability or unwillingness to maintain employment); (4) She has demonstrated a recurring tendency to engage in suicidal actions or ideations (slitting her wrists and attempting to overdose); and (5) S has reported uncertainty about her own self-image and her own sexual identity (which is manifest as confusion about both preference of partners and her own proper gender).

With a client who has the same variety of issues as Carol and who behaves in a corresponding fashion, the author believes that it is critically important to rule out conditions other than bipolar disorder before actually making a final diagnosis. With Carol, several aspects of personality and behavior could easily be attributable to other conditions. For starters, much of her erratic behavior could be the exclusive result of her drug abuse (especially with cocaine and alcohol). What causes the author to abandon this premise (albeit reluctantly) is the sheer quantity of symptoms that align with the actual array of symptoms associated with bipolar disorder. Carol demonstrates virtually of them in concert, and although drugs and alcohol are central to the continuance of her mental health issues, they are not necessarily the primary cause of them.

If the author was serving as Carol’s therapist he would additionally endeavor to eliminate borderline personality disorder, schizophrenia, schizoaffective disorder, and delusional disorder as primary. Any one of these particular types of disorders could be indicated by each of Carol’s symptoms—either alone or in combination. The author would pay very close attention to these possible candidates because of the fact that they are so similar in terms of how they are visible in clients—each contains disturbances in cognition and emotion in a way that has both positive and negative undertones (Daley & Moss, 2006). Much like the “light and dark” associated with standard bipolar disorder, these conditions can have a very similar effect: Borderline personality disorder and delusional disorder can each include impulsive actions, suicidal behavior, irrational anger and paranoia, and schizophrenia and schizoaffective disorder can each include flattened emotions, ambivalence, a lack of goal-orientation in life, delusional thinking, and paranoia (DSM-IV-TR, 2000). What is critically important, in the author’s opinion, is to eliminate any of these as a stand-alone disorder prior to reaching a clinical conclusion that Carol suffers from bipolar disorder.

The author believes that upon reaching a firm understanding of what Carol was dealing with, the best treatment approach for Carol would be one that does not directly emphasize the concept of change in too direct a manner. Carol is clearly in a psychic space where her attachment to dramatic concepts regulates much of her ability to express herself and make cognitive determinations. As is true of many who suffer from bipolar disorder (DSM-IV-TR, 2000; Daley & Moss, 2006), Carol represents herself in constant crisis. One could even speculate that much of her problematic behavior stems directly from her commitment to this abstract ideal. The author’s approach would be one that gently affirmed small positive changes (as they occurred), and one that focused on providing support over immediate or forceful re-education. In moving across the continuum of care, the author believes that he could call on his strengths in creating trust and establishing an emphatic bond with Carol in order to develop the dual goal of sobriety and less manic interference with normal functionality.

This strategy would involve a cognitive-based campaign that targeted specific reasons or trigger behind problematic consumption (i.e. drinking in anger or frustration). In trying to establish alternative behaviors that could take the place of substance abuse at certain trigger-points, the author believes that enough solidarity and dissonance could be achieved to eliminate the need for halfway-house or inpatient care. However, this route would have to be weighed against two distinct aspects of Carol’s existence: (1) A history of certain enablers in life (i.e. her parents’ willingness to cover-up her behaviors; and (2) A demonstrated willingness or ability to maintain steady employment and control impulses in the future. The author would also work to reacquaint Carol with her natural intellectual capabilities with the intent of making this a central part of her goal-setting during treatment. Should Carol fail to respond to any part of this approach, however, the author would reconsider inpatient care on an as-needed basis.

 With clients like Carol, challenges do not end with successfully reaching a diagnosis. It would appear that instead this is actually a point of departure—that place where actual therapeutic progress can truly begin (Daley & Moss, 2006). The author believes there is a distinct need to adhere to the diagnostic criteria associated with a multitude of disorders, but not only to reach a successful diagnosis. The reality is that these criteria will continue to influence and guide how therapy unfolds throughout the therapeutic relationship. As always, what remains most important is a commitment to what the client’s demonstrated needs actually are.

References

 Daley, D.C. & Moss, H.B. (2002). Dual disorders: Counseling clients with chemical dependency and mental illness. Center City, MN: Hazelden Foundation. 

American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: APA.