The Case of Sabrina

The case of Sabrina; Sabrina is 23 years old, she recently graduated from Tulane University with a degree in civil engineering. Sabrina was recruited to work in a prestigious engineering firm in Manhattan. She made a plan to move from her hometown of New Orleans to a studio apartment in New York City.

Her family and college friends threw her a going-away party. On the outside she seemed to have it all figured out, Sabrina insisted on taking the drive to New York on her own with a van full of her belongings. Along the way she stopped in a hotel in Virginia where she closed herself in her room and cried for hours.

Overwhelmed with sadness, she couldn’t find a way to pull herself out of bed and ended up staying in the hotel for three days, mostly crying and sleeping. At the end of the third day, she calls her father and told him what was happening. She described her sadness as deeper than I’ve ever felt it.

Her father assume she was struggling with the transition to adulthood and moving away from home. He immediately flew to her hotel and drove with her to her apartment in New York. She started her new job and was able to make it to work on time every day. However, she would sometimes close herself in the bathroom and cry for 10 to 15 minutes or take an extra long lunch sitting in a cafe but not eating.

Sabrina did not return calls from her friends. She declined invitations to happy hour by coworkers and other social events at work. She spent most evenings after work, watching television in the dark in her apartment. Some nights, she stayed on the couch all night and barely slept. Once an avid runner, Sabrina had only gone for a few short runs since she moved to New York city.

Sabrina’s mother and father came to visit her and immediately noticed that she had lost at least ten pounds, which was a lot to lose from her already small frame. They noticed she hadn’t unpacked many of her boxes and hadn’t decorated her apartment. They had begin to worry that she may be experiencing depression.

Something they were familiar with as Sabrina’s maternal grandmother was diagnosed with Bipolar Disorder many years ago. Sabrina brushed off her parents’ concerns, saying she was just getting used to the loneliness of the big city. However, she appeared to be down, tired, and lacking the enthusiasm she once had.

Module 3: Bipolar and Related Disorder

Bipolar and Related Disorders

In every day interactions, the term bipolar is often used loosely to describe individuals with mood changes. However, the clinical diagnosis of bipolar disorder is a serious mental health condition that causes significant impairment of functioning and distress for individuals and their families. Bipolar disorder – formerly referred to as manic depression – is more than someone with mood swings or general ups and downs. Individuals with bipolar disorder experience peaks and valleys in mood- known as lability- ranging from mania to depression. Below is a list of symptoms a client may exhibit.

Diagnosis of a bipolar disorder must meet the criteria delineated in the DSM-5. As a defining feature, bipolar and related disorders are marked by a manic and/or hypomanic (less severe) episode, during which the individual’s mood is abnormally elevated, expansive or agitated for most of the day, for at least one week (or 4 days if episode is hypomanic). A depressive episode is marked by symptoms present during the same 2 week period.

Manic/hypomanic symptoms Depressive symptoms
·     Increased energy, restlessness

·     Excessively euphoric mood

·     Inflated self esteem

·     Grandiosity

·     Decreased need for sleep

·     Racing thoughts

·     Highly distracted

·     High sensitivity to smells and touch

·     Excessive involvement in activities

·     Impulsivity

·     Hostility

·     High risk behaviors – spending sprees, drug use, gambling, sexual indiscretion

·     Psychotic features (present only in manic episodes) – Delusions, hallucinations, disorganization

·     Feels sad, empty, hopeless, worthless, excessive guilt

·     Cries frequently, suddenly or is tearful

·     Decreased interest in activities

·     Decrease or increase in appetite

·     Rapid weight loss or weight gain

·     Fatigue

·     Withdrawal

·     Poor decision-making

·     Indecisive

·     Apathy

·     Suicidal ideation

Bipolar disorders I and II, cyclothymic disorder and other related disorders exist on a continuum. Bipolar and related disorders present with varying features that should be assessed and included as part of the diagnosis. Severity level – mild, moderate or severe – as well the presence of psychotic features and state of remission (absence of symptoms) are included in the diagnosis. Specifiers of severity, psychotic symptoms and remission can be found in the DSM-5 (p.127) and your textbook (p.115) and include items such as: with anxious distress; with rapid cycling; with catatonia, etc. Therefore, becoming deeply familiar with the associated features is essential to making an accurate diagnosis.

Other important things to know about bipolar and related disorders:

  • Be aware of comorbid conditions and differential diagnoses as outlined in the DSM-5.
  • Manic symptoms may be substance-induced. It is critical to assess for drug use, including prescription or illegal substances that may have contributed to the client’s symptoms.
  • Individuals with bipolar disorder are at a very high risk of suicide, about 15 times more than the general population (Gray, 2017).
  • Bipolar disorder has an average age of onset around the mid-20’s.
  • When symptoms of mania and depression or withdrawal are present in children they will often be diagnosed with disruptive mood dysregulation disorder, although children who do meet the criteria may be diagnosed with pediatric bipolar disorder (Noller, 2016).

Source: Figure 4.3, page 125 from Gray, S. (2016). Psychopathology: A competency-based assessment model for social workers (4th ed). Boston: Cengage.

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Social Work Assessment and Intervention

Individuals experiencing manic episodes often show up in emergency rooms due to erratic, high risk, suicidal, or psychotic behaviors and symptoms. Psychiatric hospitalization may also occur during a severe depressive episode. Individuals may be brought to a hospital, psychiatric unit, outpatient mental health clinic or other mental health provider by a loved one, ambulance, law enforcement, therapist; or they may bring themselves in seeking help. Depending on the severity of symptoms and risk to self and others, the individual may be treated in an inpatient unit while they are stabilized. Psychiatric social workers in hospital or inpatient settings provide individual and group therapy, medication compliance support, family education and support, assessment and discharge planning.

Most treatment for bipolar disorder happens on an outpatient basis. Social workers are involved in comprehensive biopsychosocial assessment, treatment planning, individual/family/group intervention, crisis management, family support, psychoeducation, advocacy and other strategies. Please read the Culpepper (2014) article in your resources for a detailed review of assessment and treatment of bipolar disorder. A few important aspects are reviewed here.

A thorough client assessment should include:

  • Clinical interview detailing:
    • Duration, severity, frequency of past and current symptoms
    • Impact of symptoms on functioning: social, vocational, relationships, family roles, financial, emotional
    • Comorbid disorders or symptoms, especially anxiety disorders, PTSD, ADHD
    • Substance, alcohol, medication use or abuse
    • Biopsychosocial history and current functioning
    • Family history of health and mental health conditions and other risk factors
    • Past and current treatments
    • Suicidal or homicidal ideation, plan, attempts, history
    • Support system, concrete and emotional resources, strengths
  • Review of medical records
  • Collateral interviews with family members and other care providers
  • Use of evidence-based screening or diagnostic tool
    • g. Mood Disorder Questionnaire (MDQ)
    • Composite International Diagnostic Interview 3.0 (CIDI)

(Culpepper, 2014; Gray, 2017)

Treatment for bipolar disorder centers around symptom management and minimizing the impact of the disorder on client functioning. Pharmacologic treatment is the primary method of managing bipolar symptoms, especially manic episodes, impulsivity, psychotic symptoms, outbursts and high risk behaviors. Antipsychotic medication, mood stabilizers and other oral medications have been found to be effective in treating both manic and depressive symptoms. Many individuals will take multiple medications – as many as four – to treat bipolar symptoms simultaneously. The side effects of these medications are often pronounced and potentially dangerous over time, including weight gain, increased cholesterol, increased risk of diabetes. Other uncomfortable side effects may serve as deterrents to individuals to compliance with a medication regimen, such as blurred vision, diarrhea, nausea, dry mouth, tremors, fatigue, headaches, cognitive impairments, rash, hair loss, dizziness, risk of overdose (Nollen, 2016).

Compliance with medication is very important in ongoing management of symptoms. However, the possible long term health detriments and unpleasant side effects are barriers to stabilization. As well, when individuals experience a manic episode, they often feel “on top of the world” and don’t believe anything is wrong. Many individuals stop taking their medication when a manic episode approaches. Therefore, by the time they are back in front of a doctor or psychiatrist, they are in need of medication stabilization.

It is important to note that antidepressants are typically discouraged in the treatment of bipolar and related disorders, especially Bipolar I as it is thought that these medications might induce a manic episode. However, individuals with bipolar disorder are likely to spend three times as many weeks in a state of depression versus manic (Gitlin, 2018). Practitioners are often seeking to alleviate the client’s depression. As a result, the use of antidepressants to treat depressive symptoms is an increasingly controversial topic in the treatment of Bipolar II, cyclothymic and other related disorders.

In conjunction with symptom management through medication, there are several psychosocial treatments that can be provided by social workers that have demonstrated positive outcomes for bipolar clients:

Purpose Instructions

The purpose of this assignment is to practice developing a treatment plan for a client experiencing a mental health condition. The treatment plan should include goals, objectives, intervention strategies, and methods of evaluation.

Course Objectives

  • CO 2: Master the classification system DSM-5 and relate it to the major mental disorders.
  • CO 3: Show how to relate diagnosis, treatment planning and prognosis to psychopathology. CO 3: Adapt assessment models to reflect an understanding of persons from diverse backgrounds.

Requirements

  1. This paper will be graded on use of citations, use of Standard English grammar, sentence structure, and overall organization based on the required components as summarized in the directions and grading criteria/rubric.
  2. Create your exercise using Microsoft Word (a part of Microsoft Office). You can tell that the document is saved as a MS Word document because it will end in “.docx”
  3. Follow the directions and grading criteria closely. Any questions about your assignment may be posted under the Q & A Forum.
  4. The length of the exercise is to be no less than 2 pagesand no greater than 3 pages excluding title page and reference pages.
  5. APA format is required with both a title page and reference page. Use the required components of the review as Level 1 headings (upper and lower case, centered, boldface):
    Note:Introduction – Write an introduction but do not use “Introduction” as a heading in accordance with the rules put forth in the Publication manual of the American Psychological Association.

Guidelines

For this assignment, you will use the case of Sabrina presented in Module 3. In Module 3, we discussed developing SMART goals for Sabrina’s treatment plan. In this assignment, you will develop a more comprehensive treatment plan using this template (please be sure to delete the example from the template).

Your treatment plan should provide specific details about the presenting symptoms, client competencies, SMART goals and clearly defined outcomes. You should search the literature to identify evidence-based or evidence-informed intervention strategies and methods for evaluating the client’s progress in treatment. Be sure to put time frames on the outcomes and treatment, but really think this through rather than selecting a random duration. For instance, most cognitive behavioral treatment are or 12 weeks, followed by an evaluation to determine if treatment should continue.

  1. Symptoms/Problems/ Needs Severity and duration (use DSM-5 criteria)

Example:

Client is exhibiting symptoms of social anxiety

Moderate to severe for 4 years

  • Fear and anxiety in social situations
  • Avoidance of social situations and interacting with friends and family
  • Currently unemployed due to social anxiety
  • Fear of dating/romantic relationships
  • Avoids contact with health professionals, including doctor and dentist
  1. Client Resources/ Competencies
    • Client is a registered nurse with 8 years of experience.
    • Client has several close friends and family members who care for her and want to spend time with her.
    • Client enjoys her dog and misses taking him to the dog park.
    • Client is highly motivated to get back to work.
    • Client is motivated to engage in treatment.
  • Goals and Objectives/Measurable Outcomes

Client will demonstrate reduction of social phobia by 75% within 6 months:

  • Make contact with health professionals, attend doctor and dentist appointments within 3 months
  • Take dog to the dog park twice per week for 6 months.
  • Socially engage with a friend or family members at least twice per month for 6 months
  • Report a reduction in fear and negative thoughts in social situations

Client will re-enter the workforce within 6 months:

  • Develop a plan for employment
  • Apply to 3 or more jobs and participate in interview process
  • Maintain employment
  1. Treatment/Intervention Frequency and Duration
    • Cognitive behavioral individual treatment with social worker, weekly for 3 months (to be re-evaluated, may extend to 6 months)
    • Social Anxiety support group, online – 2x/month for 6 months
    • Medication evaluation with psychiatrist ; Adhere to medication regimen as prescribed for duration determined by treating psychiatrist
    • Meet with vocational rehabilitation specialist to develop plan for employment
  2. Methods of Evaluation
    • Client self-report
    • Mini Social Phobia Inventory, every 3 months
    • Medical and service records/reports

Grading Criteria

Your paper will be graded based on following criteria:

Criteria Description
Symptoms/Problems/Needs Severity and duration

(20 Points)

Treatment plan includes a clear description of the client’s presenting symptoms, severity and duration
Client Resources/Competencies (20 points) Treatment plan includes client’s strengths, resources and competencies to be used in treatment
Goals and Objectives/Measurable Outcomes

(30 points)

Treatment plan includes goals and objects that are SMART
Treatment/Intervention Frequency and Duration

(30 points)

Treatment plan includes evidence-based interventions strategies, with specified frequency and duration
Methods of Evaluation (20 points) Treatment plan includes evidence-based methods of evaluating client’s progress in treatment.
Clarity of Writing (20 points) Writing is clear, concise, free from grammar and spelling errors. Correct, unbiased clinical language is used.
APA Style (10 points) Sources are correctly cited
Total (150 points) A quality essay will meet or exceed all of the above requirements.