Do Catherine’s temper outbursts seem to be related to environmental stressors?

Question

DSM Diagnosis
F31.12 Bipolar I Disorder, most recent episode manic, moderate, with rapid cycling.
F10 Alcohol Use Disorder, moderate
Mild Arthritis in ankle (by client’s report)

Rationale
Catherine meets most of the criteria for bipolar disorder. Her manic episodes are characterized by unrealistically inflated self-esteem, a decreased need for sleep, racing thoughts, distractibility, an increase in unrealistic goal-directed activity, and involvement in activities with a high potential for painful consequences. Her major depressive episodes, which seem to alternative with her manic episodes, feature a depressed mood and loss of interest in most life activities. She experiences hypersomnia, a slowing down of her physical functioning, loss of energy, feelings of worthlessness, and a diminished ability to concentrate. Catherine fluctuates between mania and depression three or four times per year. The specifiers were chosen because of Catherine’s reports that, when “stable”, her moods fluctuate daily between feelings of sadness and elation.
The diagnosis of an alcohol use disorder is supported by Catherine’s reports of frequent, but not continuous, drinking, usually in bars. This seems to be a major social outlet for her and may also be a means of self-medication. The drinking contributes to her problematic social functioning and puts her in situations of danger (such as drinking while driving). She is more at risk to be violent when she has been drinking, although her alcohol use doesn’t seem to significantly affect her work performance. Even though Catherine has not tried to stop using alcohol, she does not exhibit signs of tolerance or withdrawal. A severity specifier of “mild” has been assigned, with the recognition that more information may be required to discover whether this is accurate.

Additional Information Needed
It would be helpful to obtain the client’s medical records to learn more about her medical as well as psychological history. It may also be helpful to speak to her husband individually to obtain his perspective on their relationship. Further assessment of her social history can provide details about the patterns of her interpersonal interactions and thus help to determine whether she has a personality disorder. More information should be sought from the client and her husband about the nature and extent of her substance use to determine whether she has an alcohol use disorder and to determine the relationship between her mood episodes and her drinking. The client should also be questioned further about the frequency and amount of her alcohol use to evaluate further whether has developed a tolerance to it.

Risk and Protective Influences
Catherine’s mother may have had a depressive disorder, given the client’s description of her as drinking “too much” and being “sad” much of the time. If so, Catherine would have had a higher than average risk of developing a mood disorder herself. Catherine’s risk influences for a poorer outcome of her bipolar condition include her rapid cycling, comorbid alcohol use disorder, inadequate social support, inconsistent structuring of her activities of daily life, and lack of insight into the disorder (which has thus far resulted in her failure to seek help). Protective influences include a relatively late age of onset (her early 20s), a stable and supportive husband, regular health check-ups, community support (with regard to her apparently sympathetic employer) and ongoing intervention (if she persists with this).
What questions can be used to assess for additional strengths in Catherine?
1. What qualities has Catherine demonstrated to make it to this point in her life, despite the many problems she has endured?
2. How has Catherine been able to manage her life this well with all the difficult things she’s been through?
3. What has Catherine done well in the past? What goals has she been able to achieve? What strengths and supports did she draw upon to do these things?
4. Have there been times when Catherine’s was able to get along with people and control her drinking during her “up” periods? What was she doing differently then? Who was she with?
5. When can Catherine “stand up” to the “hyperactivity,” the “up and down” moods, “the fighting,” and the “beer drinking?”
6. What will Catherine’s future look like when her current problems are solved? What will she be doing when she longer has these problems? What new or additional goals will she develop for herself?
7. What does Catherine get out of drinking and fighting? That is, what is beneficial to her about those practices? On the other hand, what are the negative consequences for her?

Intervention Plan
Goal #1: Client will understand the nature of bipolar disorder. Interventions will include weekly counseling for three weeks focused on understanding the disorder, its course, risk and protective influences, and available interventions; and twice weekly counseling for three weeks focused on identifying specific mood triggers and their relationship to problematic behaviors

Goal #2: Client will understand the potential dangers of her ongoing alcohol abuse. Interventions will include twice-weekly counseling for three weeks focused on enhancing her motivation to control alcohol use and referral to Alcoholics Anonymous if client is receptive to this.

Goal #3: Client will make decision about the use of medications to control her mood swings. Interventions will include a consultation meeting with the agency physician and the social worker’s efforts to resolve her ambivalence about medication.

Goal #4: Client will develop and maintain a structured daily schedule, through individual interpersonal and social rhythm therapy weekly for six weeks

Goal #5: Client will identify and strengthen relationships with supportive others who can help her to monitor her mood, through the same intervention as noted above

Goal #6: Client will acquire new strategies to manage angry feeling toward others. Interventions will include a referral to agency anger management group and the social worker’s weekly monitoring of that intervention.

Critical Perspective
Catherine’s symptoms of bipolar disorder cannot be fully separated from the influences of her substance abuse and possible personality disorder as of yet. She does meet most of the criteria for bipolar disorder, but because those symptoms overlap considerably with the other two disorders it is not clear to what extent the mood disorder is affected by biological or psychosocial mechanisms.

Answer 1

There is no evidence in Catherine’s current presentation or her history of a relationship between environmental events and temper outbursts. Her outbursts seem related instead to her manic episodes, which do not appear to have external precipitants.