by Tabetha
Cooper
Introduction
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| medicalook.com |
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.
Case
Study
| gabehavioral.com |
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.
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| cureanxiety.com |
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.
 |
| ncbi.nlm.nih.gov |
Bipolar
Disorder
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).
| anxietypanic.com |
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.
Genetics/Familial
Traits
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).
| medscape.org |
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.
Brain
Abnormalities
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.
Neurotransmitters
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.).
| medscape.org |
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.
Remedies/Medical
Treatments
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).
| bipolar-lives.com |
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.
Conclusion
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.
References
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
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