During the 2-year period, symptoms are not absent for more than 2 months at a time.
Individual has no history of mania or hypomania.
Individual experiences significant distress or impairment.
(Information from: APA, 2013)
Bereavement entails the mourning of the death of a loved one. The symptoms of bereavement can include many of the same symptoms as a major depressive episode, but these symptoms clearly occur as the result of the loss of a loved one.
For the same 2 weeks, the individual also experiences at least three or four of the following symptoms: Considerable weight change or appetite change
Daily insomnia or hypersomnia
Daily agitation or decrease in motor activity
Daily fatigue or lethargy
Daily feelings of worthlessness or excessive guilt
Daily reduction in concentration or decisiveness
Repeated focus on death or suicide, a suicide plan, or a suicide attempt
Individual experiences significant distress or impairment.
(Information from: APA, 2013)
For 4 days or more, the individual displays a continually abnormal, inflated, unrestrained, or irritable mood as well as continually heightened energy or activity, for most of every day.
Individual also experiences at least three of the following symptoms: Grandiosity or overblown self-esteem
Reduced sleep need
Increased talkativeness, or drive to continue talking
Rapidly shifting ideas or the sense that one's thoughts are moving very fast
Attention pulled in many directions
Heightened activity or agitated movements
Excessive pursuit of risky and potentially problematic activities.
Individual experiences significant distress or impairment. (Information from: APA, 2013)
Presence of at least two of the following symptoms within a 1-year period:
Substance is often taken in larger amounts than intended or over a longer period than intended
Unsuccessful efforts or persistent desire to reduce or control substance use
Much time spent trying to obtain, use, or recover from the effects of substance
Failure to fulfill major role obligations at work, school, or home as a result of repeated substance use
Continued use of substance despite persistent social or interpersonal problems caused by it
Cessation or reduction of important social, occupational, or recreational activities because of substance use
Continuing to use substance in situations where use poses physical risks
Continuing to use substance despite awareness that it is causing or worsening a physical or psychological problem
Craving for substance
Tolerance effects
Withdrawal reactions
(Information from: APA, 2013)
The attack includes at least four of the following:
Increased heart rate or palpitations
Perspiration
Trembling
Shortness of breath
Choking sensations
Discomfort or pain in the chest
Nausea or other abdominal upset
Dizziness or lightheadedness
Feeling significantly chilled or hot
Sensations of tingling or numbness
Sense of unreality or separation from the self or others
Dread of losing control
Dread of dying
(Information from: APA, 2013)
No pattern of mania or hypomania.
(Information from: APA, 2013)
Hypomanic or major depressive episodes may precede or follow the manic episode.
(Information from: APA, 2013)
Presence or history of hypomanic episode(s)
No history of a manic episode
(Information from: APA, 2013)
A psychodynamic therapist would use psychoanalytic treatment techniques such as free association, or letting the client talk about whatever comes to mind, and therapist interpretation, which involves giving insight and offering an opinion on patterns noticed in the client’s free association and other indicators such as dreams. A psychoanalyst would treat John by seeing him 3–5 times per week for several years. Psychoanalysis is costly, and it requires a large time commitment.
Interpersonal therapy focuses on problems in significant relationships in the patient’s life. Interpersonal therapists treat patients by focusing on their current relationships with the most important people in their lives. These people include partners and spouses, parents, roommates, and children. For John, these would be his parents, his roommate, and other friends.
CBT involves challenging distorted thoughts and helping patients change maladaptive behaviors. Cognitive-behavioral therapists work with clients to address their maladaptive thoughts in each phase of the disorder. In John’s case, treatment for his depressive episodes would be similar to treatment of major depressive disorder, including getting him to engage in enjoyable behaviors and challenging negative automatic thoughts. John’s treatment when in a manic episode would include working with him to discourage reckless behavior and to address any maladaptive beliefs. CBT would also include monitoring John’s mood to try to predict his mood episodes.
Medication involves taking a chemical agent prescribed by a medical doctor to alter brain chemistry, which subsequently alleviates symptoms. A psychiatrist, who has a medical degree (MD), would be able to prescribe patients with bipolar disorders a mood-stabilizing medication such as lithium. In John’s case, this medication will help reduce the symptoms of his manic and depressive episodes. In addition, this medication would prevent John from developing symptoms of a mood episode in the future. As a therapist, you would continue to meet with John regularly to monitor his symptoms and to refer him to a psychiatrist to adjust the dose of his medication as necessary.
Author: Taryn A. Myers, PhD, Virginia Wesleyan University
Please note: Clinical Choices allows you to enhance and test your understanding of the disorders and treatments covered in your textbook, in a simulated case study environment. It is not intended to replicate an actual intake interview or therapy session or provide training on therapeutic techniques. Clinical Choices is for educational purposes only and is not intended as a substitute for clinical training.
The receptionist hands you the intake paperwork prior to your interview with your new client, John, and mentions that his parents have brought him in. They seem very worried about their son. Select the button to review the paperwork before you begin the interview.
Psychological Clinic
Intake Paperwork
Client Name: John
Age: 20 years old
Gender: Male
Ethnicity: Caucasian
Occupation: College student
Current living situation: I live in an off-campus apartment with my roommate.
Why are you seeking services at our clinic? My parents brought me here. They say they are worried about me. I’m not sure why they are freaking out so much. I feel like I have had a personality transplant. I do not feel like myself, and I am having a hard time concentrating, but I don’t think I am as sick as my parents think I am.
You will now ask John and his parents a number of questions you would typically ask during the intake interview. As you conduct the interview with John, begin to think about his symptoms, what his diagnosis might be, and later, what type of treatment might be most helpful to him. Select the “play” button to hear John’s and his parents’ responses to your questions. To read the transcript for these answers, select the “transcript” button.
"Hi, John. It’s good to meet you and your parents. What we are doing today is called an intake interview. I’m going to have you tell me what brought you here today, and I’m going to ask you some questions that I ask everyone who comes to the clinic. This information will tell me how best to help you. This may mean having you continue to see me for therapy at this clinic, or it may involve referring you to another mental health professional or facility. Let’s start. Tell me about what brought you to the clinic today."
John: [speaking very quickly] My parents made me come. I don’t really know why. The only thing I can think of is [pauses]… I feel like I’ve had a complete personality transplant, maybe in like the last few weeks or so. I don’t think I’m a super creative or original person, but all of the sudden I have, like, so many ideas about ways I could improve my life... ideas for new projects.... [interrupts himself] like, I had this awesome idea! I am going to start a business buying and selling musical equipment on Craigslist. So I bought a bunch of old guitars online. I’m going to fix them up and resell them for a profit. Problem is... I used my credit card to buy them… and my parents found out because they get the bill. [turns to parents, somewhat angrily] They don’t believe in me at all! They can’t see what a great idea this is! I was going to fix them up before they got the bill, but then I got an even better idea! I was watching TV late one night... I don’t really need much sleep these days... and I saw this great opportunity! I could become an online advertising salesrep! I had to pony up a bit more cash up front for that, so I put that on the credit card too, but it’s totally fine… totally... I know it’s a “sure thing” and I’ll be able to make this money back and then some before the next payment is due.
Mom: [quietly with concern] We are really concerned. John has been acting strangely lately. And then we got the bill for the credit card we cosigned for John – and this was for emergencies only! And the bill was over $2,500!
Dad: [jumps in, sounding incredulous] He spent over $1000 online for these old guitars. When I asked him about it, he told me he was going to refurbish them and resell them for a profit. Now, John has always enjoyed playing the guitar as a hobby, and he’s pretty darn good at it, but he has never actually refurbished anything. I don’t even think he owns any tools!
Mom: [breaking in] And then the online advertising thing!
Dad: That was another $1,500! He tried to tell us it was a “sure thing”; that he would have a profit before the payment was due. Well, it’s due tomorrow, and he has yet to bring in a cent!
Mom: [upset] He was always so careful with money in the past. What’s happening, John?
"That sounds difficult for all of you. John, what other concerns are you having at this time?"
John: [speaking quickly and sounding annoyed] None! I really don’t understand why I am here. Other people have a problem, not me. Everyone else is moving in slow motion … I don’t have time to wait around for them to “get it.” Why can’t they just keep up? Why can’t they just believe in me? I told Calvin ... he’s my roommate … my ideas about the guitars, and he was such a jerk about it– he kept pointing out things he said could go wrong. And mom and dad don’t understand me – they even asked if I am on drugs! [contemptuous] On drugs! Don’t you guys even trust me? Don’t you get that I’m finally seeing the world clearly?
Mom: [trying to be empathetic and sensible] Calvin says that you are talking a mile a minute! He said it seems like you’re having a hard time getting all of your ideas out. Calvin is really worried about you, John. He is worried that you are wasting your money!
Dad: [breaking into back up Mom] You were talking so fast, son! I could barely understand what you were saying… your words were all garbled. You were just not making sense. It sounded like you were on drugs! Something is going on, John.
Think about which symptom could potentially cause serious issues for John down the road.
"What areas of your life have been affected? How is your schoolwork going?"
John: [excited] School is going great! I’m not worried about my grades. I’ll ace the tests without going to class... I don’t need to do any of those worthless assignments. I tried going to class, but it’s just so boring... [interrupts himself] not to mention a huge waste of time! I could be making money! My friends keep giving me a hard time about it, but they’re just jealous of my ideas and how quickly I can learn things!
Think about the fact that John interrupts himself during his answer.
"Tell me about your sleeping habits. Have you had any difficulty falling asleep or staying asleep?"
John: I don’t get tired any more. I don’t need to sleep. I’m sleeping, like … 2 or 3 hours a night and I wake up feeling great and ready to go! …to work on my next project!
Dad: His roommate told us that John is up most of the night and claims he is not tired. What do you mean you’re not tired? That can’t be healthy! John, you’re going to get even sicker if you don’t get enough sleep!
"Have you experienced any psychological symptoms in the past?"
John: I don’t remember. I guess I was depressed once in high school. I can hardly remember that now. I really feel great now!
Mom: I’ve always been a little concerned that John was too sensitive. He used to worry about small things all the time. And then when he was 17…
Dad: [breaking into finish Mom’s sentence] ... that girl broke his heart.
Mom: [sadly, reminiscing] He had been dating her for an entire year. Then she broke it off out of the blue and started dating another boy within a few weeks. John tried so hard to get her back. He left her multiple voicemails and text messages every day. She broke his heart. He just seemed so down. He stopped hanging out with his friends … he always had an excuse not to go to events or parties when they invited him out. He had no appetite and lost weight … something like 15 pounds in only a couple of months. I was so worried about him… John, you looked like you were wasting away.
Dad: We tried to get him to see the doctor.
Mom: Or to talk to someone like you … like a counselor. But he wouldn’t hear of it!
Dad: After a few months, he got over it. He started hanging out with his friends again.
Mom: [reminiscing, smiling] It was so nice to see him laugh and smile again! I was so relieved it was over.
Dad: I was glad he finally got over that girl. She wasn’t worth all that, son.
According to John and his parents, what symptoms did John exhibit when his girlfriend broke up with him? Select all that apply.
Think about what John and his parents told you during the interview, or listen to the interview again to review his symptoms.
Think about John’s symptoms that you identified on the previous screen and how they match up with the disorders.
"Tell me about your family. What was it like growing up in your household?"
John: I have a sister, 6 years younger and a little brother, 8 years younger than I am. They’re pretty cool. Growing up, you guys seemed like you didn’t have time for me.
Dad: [a little defensively] Well, we sure didn’t plan to have kids as quickly as we did. We weren't really ready to start a family.
Mom: John was certainly a surprise. We were married – of course! I quit my Master’s program when I had John. When he was two, I had to get a part-time job as an accountant to help out and ended up staying there. Sometimes, I regret that I wasn’t able to finish my degree. But I loved being able to spend time with my kids when they were younger.
Dad: And because I work in the banking industry, we do fine, now. But those first few years were tough.
Mom: After 5 years or so, we felt okay having more kids. I feel like we were able to be much better parents then. I sometimes feel guilty about how difficult things were during your childhood, John.
"John, can you describe your relationship with your parents?"
John: We’re really close. I usually call them at least once a week… I guess I haven’t lately … I’ve just been too busy with all my projects. Still, I don’t understand why they had to jump in the car and drive 2 hours just because my roommate Calvin called them. [To his parents] I mean, c’mon! Don’t you guys trust me anymore?
Think about how John usually interacted with his parents.
"How did John do in school growing up?"
Mom: In school, John was generally an A/B student. He was uncomfortable being the center of attention - he didn’t speak up in class much, but he was very conscientious about his school assignments and rarely missed a day of school.
Dad: He had several close friends. He’s known these kids since kindergarten. They all hung out together in high school, too.
"Has anyone in your family ever had a mental health problem?"
John: Not that I know of. My family is awesome. I mean … who isn’t a little nuts? Wait, seriously… wasn’t Grandpa a little crazy?
Mom: [nodding in agreement] My father did have had a lot of trouble with mental problems. He was diagnosed with… [searching for the correct word] what do they call it now… it was called manic-depression… yes, bipolar disorder… I think when he was in his 30’s. He had to be hospitalized. He was on medication, but he stopped taking it sometimes, and then it would be really hard to be around him.
Dad: He had an episode like this around the time John was born.
Mom: It was almost too much for me at the time. It made our lives so stressful, taking care of a young child and trying to care for Dad.
Dad: [agreeing] Those years were really tough.
Mom: I’ve always wondered if John is so shy and serious and melancholy because things were so stressful those first few years.
How could John’s grandfather’s diagnosis have influenced what is happening to John now? Select all that apply.
Based on the information you just got from John and his parents, think about the ways in which John’s grandfather’s illness might have directly affected John.
"John, do you drink alcohol or use any substances? If so, how much and how often? If you would feel more comfortable, we could ask your parents to leave the room while you answer this question."
John: [raising his voice] They don’t need to leave the room – I want them to hear this! I don’t see how that matters! I am just seeing the world more clearly, and if I go to parties, so what? I’m in college! And Calvin didn’t have any right to call my parents to have them come get me just because he thinks I’m doing drugs. I’m so frustrated with them all. This really ticks me off! Can’t they just leave me alone and let me work on my projects? They’re getting in the way of me making money. I only came here because I feel like I didn’t have a choice… I was sure it would be a huge waste of time. I was obviously right about that one, just like I’m usually right about everything else!
Dad: Your roommate has some real concerns. He says he found you in a separate room at that party on Friday night hanging out with people who are known drug users.
Mom: Calvin said he tried to get you to leave the party with him. He said that you became angry and physically threatened him! Really, John David! I did not raise you to be violent, and Calvin is your friend!
Dad: Calvin called us because he was worried. He said that we should come and get John. Calvin is a good friend, John. That’s a real man who looks out for his friends.
Mom: And then we drive all the way here, and John, you didn’t even get back until all hours of the morning. Where were you? What were you doing, John?
Dad: We made an appointment with the family physician. We are taking him there tomorrow to get him checked out. We had his bags all packed when he finally graced us with his presence at whatever hour of the morning that was. We’re very worried about you, son.
Think about John’s symptoms and whether they are mental or physical.
Which of the following symptoms is John currently experiencing? Select all that apply.
Think about the information you got not only from what John and his parents said, but also from how John was speaking during the interview.
From the File. You remember a former patient who exhibited symptoms similar to John’s. You review this case to help you diagnose John.
It was the summer before my junior year of high school. I would sleep for an hour a night. And my mind was just constantly racing. It was like a TV screen, but the channels were just flipping and flipping and flipping and flipping.
I just reached these euphoric highs where I felt like I was on top of the world, where nothing could stop me, nothing could bring me down. Then, I would have this depression, the lowest of the low. So it was just this kind of monstrosity of ever-changing emotions.
In making your choice, think about the following symptoms that John exhibits:
- Spending money without thinking about the consequences
- Feeling like he does not need much sleep
- Racing thoughts
- Friends noticing his behavior and expressing concern
When making your choice, think about the following symptoms that John exhibited in the past:
- Not enjoying spending time with his friends
- Feeling down
- Loss of appetite
- Weight loss
Think about the types of episodes John has experienced.
In making your choice, think about the fact that research on the brain and genetics has given us the most helpful information about bipolar disorder in recent years.
EPILOGUE
John started meeting with you on a regular basis for cognitive-behavioral therapy. In addition, you referred John to a psychiatrist, Dr. Samuelson, for medication management. Dr. Samuelson put him on lithium and carefully monitored his dosage. Even so, John experienced some side effects, including trouble concentrating, drowsiness, and increased thirst. Also, whenever he began feeling manic, he would want to stop taking the medication. As his therapist, you worked with him on addressing some of his maladaptive thoughts, such as his idea that his manic state was the “real John.” With your help, John was able to use behavioral techniques such as setting a reminder on his phone and using a pill organizer to help him settle into a routine and remember to take his medication. After taking the rest of the semester off from college, John returned to school the following semester. He and Calvin made amends and continued to live together. John tries to remember to call his parents on a regular basis to reassure them that he is doing fine. He decided to major in business so that he can explore some his “entrepreneurial” ideas and learn to implement them in realistic ways.
Real World Application
Watch this video about how one family struggled with having to involuntarily hospitalize their father due to his bipolar disorder—called “sectioning” in the United Kingdom. Then answer the question that follows.
MAN: This is the area into which someone will be brought when they're brought by the police.
RACHEL: Yeah.
MAN: Under what's called Section 136 of the Mental Health Act.
RACHEL: Why would someone with bipolar need to be sectioned?
MAN: There's a huge variety of severities so this condition. They might be overactive, have all sorts of grandiose of unfeasible plans and schemes, and because there's the loss of judgment, the person will typically not necessarily realize that they're unwell and needing treatment. Sometimes the only way, then, to persuade, or to get the person to have adequate treatment is to take away their freedom and detain them. Section them.
RACHEL: I know how hard it was for me at the time, but I wanted to find out what it was like for my sister Nicola, as she was the one who had to sign the papers to have Dad sectioned. How old was you?
NICOLA: 20.
RACHEL: Yeah. And you had to sign Dad in, didn't you?
NICOLA: I did, because obviously I was his next of kin, cause he and my mom were divorced. And obviously it's horrible, because you don't want to see your dad having to go into hospital, but that was the last resort. We all said at that time we was going to agree.
We wouldn't tell him who signed the papers or nothing, so I don't know who told him, but somebody told him that I signed him in, and he was just very hostile towards me. He was looking at me like he just wanted to kill me.
RACHEL: It affected your relationship with him for quite a long time, didn't it?
NICOLA: Well, he didn't start talking to me properly, or have any, like, interest in me probably until I was about 28. He always made it feel that, oh, I can't have a laugh with Nicola, because she may get me sectioned.
RACHEL: Do you feel guilty, anyway?
NICOLA: It made you feel guilty soon as you did it, but I just have to be strong and just say I did it for the right reasons. Just where would he be now if he wasn't sectioned?
RACHEL: Certainly I don't think he--
NICOLA: Would he be alive?
RACHEL: Yes, I think--
NICOLA: Would he have anything left to his name? Would he be wrapped around a tree because of the way he drives? Would someone else have hurt him because of the way he was antagonizing people? What would have happened?
RACHEL: Yeah.
NICOLA: Because there he's invincible. When he's manic, he's invincible. He's dominated my whole life for-- 18-- 12 years. 12 years he's dominated it, like just for me worrying about him. But I have to be honest. Like, he's not worried about me. He's not worried about how my life is going. He doesn't care. But at the end of the day, I love my dad, and I'll never stop loving him, but if I ever got here, would he do the same for me? But I don't do it for him to do it for me.
RACHEL: You know what? You-- I'm proud of you for taking on that responsibility, and all these years. I couldn't be as strong as you.