Case Study
Betty, a 30-year-old unmarried schoolteacher of Caucasian ethnicity, was brought into the emergency room by her concerned parents. Upon her arrival, she encountered the ER Psychiatrist, who happened to be wearing a green tie, leading her to mistakenly assume his name was Dr. Green. In a whimsical moment, she playfully comforted the doctor for not having green eyes, suggesting that he could change their color with sheer determination. During a brief five-minute interaction, Betty rapidly shifted through eight different topics of conversation.
Betty's demeanor took a flirtatious turn as she encouraged the doctor to examine what she described as a "bruise" on her inner thigh. However, when he suggested she consult another physician for the examination, her mood quickly turned to anger, and she used strong language to express her frustration.
This episode had begun a week prior when Betty experienced a distressing breakup with her boyfriend. Since then, she reported a severe disruption in her sleep and eating patterns. Astonishingly, she had spent $10,000 on sending random text messages to her students and impulsively booked an Alaskan cruise.
In addition to her erratic behavior, Betty had been hearing distressing voices that repeatedly labeled her a "dumb whore" and urged her to harm herself. It's worth noting that Betty had encountered similar episodes three times within the past two years, each culminating in a severe state of depression. In between these episodes, she appeared coherent and capable of maintaining her job, supporting herself, and living independently.
Please answer the following:
- Primary Diagnosis (using diagnostic code if applicable):
- Secondary Diagnosis (using diagnostic code if applicable):
- Rule Out Diagnosis (using diagnostic code if applicable):
- Symptoms that support each of your diagnoses. Also, any psychosocial factors that may be of concern.
- A brief treatment plan for the patient.
Primary Diagnosis: Bipolar I Disorder, Current Episode Manic (F31.11)
Secondary Diagnosis: Borderline Personality Disorder (F60.3) . Rule Out Diagnosis SchizophreniaF20.9)
Symptoms that support each of your diagnoses:
Bipolar Disorder:
Rapid and frequent mood shifts, ranging from flirtious to angry
Imp behaviors, such as excessive spending and booking an Alaskan cruise
Disturbed sleep and eating patterns
Grandiose beliefs, demonstrated by suggesting the doctor could change his eye color
Auditory hallucinations, hearing distressing voices urging self-harm
Borderline Personality Disorder:
Intense and unstable interpersonal relationships, demonstrated by playful flirting followed by anger when the doctor suggested consulting another physician
Impulsivity, as seen in the impulsive text messaging to students and impulsive booking of a cruise
Identity disturbance, evidenced by rapidly shifting conversations and assuming the doctor’s name based on his tie color
Psychosocial factors:
Recent distressing breakup with her boyfriend may have triggered the current manic episode.
The pattern of recurring episodes of severe depression suggests a cyclical nature of mood disturbance.
Difficulty maintaining stable relationships and engaging in impulsive behaviors may impact her personal and professional life.
Treatment plan for the patient:
a) Medication:
Mood stabilizers, such as lithium or valproate, to manage manic symptoms and prevent future mood episodes.
Antipsychotic medication, such as risperidone or olanzapine, to address auditory hallucinations and stabilize mood.
b) Psychotherapy:
Dialectical Behavior Therapy (DBT) to address the symptoms of Borderline Personality Disorder, providing skills for emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness.
Cognitive-Behavioral Therapy (CBT) to address distorted thinking patterns, promote healthier coping strategies, and improve problem-solving skills.
c) Supportive Measures:
Educating the patient and her family about bipolar disorder, borderline personality disorder, and the importance of medication adherence.
Establishing a consistent daily routine to help stabilize mood and provide structure.
Encouraging self-care practices, such as regular exercise, healthy sleep hygiene, and balanced nutrition.
Involving family members in therapy sessions to improve understanding and support.
A collaborative approach involving medication management, psychotherapy, and supportive measures is crucial for addressing both the manic symptoms of bipolar disorder and the underlying difficulties associated with borderline personality disorder. With appropriate treatment and ongoing support, Betty can achieve better stability in her mood, enhance her coping skills, and improve her overall functioning.