Are any of Ms. Daniels’ emotional states and behaviors normal reactions to the aging process?

Question

DSM Diagnosis
F31.31 Bipolar I Disorder, most recent episode depressed, mild
Glaucoma; Peripheral Vascular Disease; Hypertension; Osteoporosis;
Osteoarthritis; Hypothyroidism; Allergic Rhinitis; Gastroenteritis Reflux Disease (doctor’s report)

Rationale
The diagnosis of bipolar I disorder was chosen because of the client’s self-reported history of multiple manic and major depressed episodes. The social worker has not observed a manic episode, and it is possible that the client has not experienced one since beginning to take lithium ten years ago. The client’s manic episodes are characterized by unrealistically inflated self-esteem, a decreased need for sleep, racing thoughts, an increase in unrealistic goal-directed activity, and involvement in activities with a high potential for painful consequences. Ms. Daniels is more often depressed, as she appears today, experiencing a depressed mood and a loss of interest in most of her life activities. Her depression appears to be mild to moderate, and she meets at least three of the criteria for a partial remission status. These criteria include feelings of sadness, diminished interest in activities, and loss of energy.

Additional Information Needed
Although the client provided information that she experienced numerous depressive and manic episodes between college and the age of 66, she only shared details of one depressive episode and one manic episode, adding that the others episodes were “similar”. Knowing more about the pattern of her symptoms might provide a better diagnostic picture.
Apparently, Ms. Daniels was only assessed with bipolar disorder ten years ago, and it would be interesting to know with what she was diagnosed before that time and why it took so long for her to receive the correct diagnosis. Additionally, information about anxiety symptoms might rule out any anxiety disorders. A family history of mental health would also be helpful, as well as taking an assessment of Ms. Daniel’s substance use history. She mentioned being prescribed anti-anxiety medication, but that is all we know of any potentially addictive drugs. Finally, there is a need for more exploration around Ms. Daniel’s long-term interpersonal patterns and her beliefs about ageing, as well as whether her current emotional states and behaviors are normal reactions to the aging process.

Risk & Resilience Influences for Ms. Daniels’ Bipolar Disorder
It is unknown the biological influences that might have lead to the development of Ms. Daniel’s disorder, and we do not know about her family history of mental illness, or any abuse history that she may have experienced. Information is lacking about factors related to the course of her illness, as well. On the risk side, Ms. Daniel’s had a relatively early age of onset (college-age) and seemed to have a distant relationship with her family in the past; there also appears to be some conflict with her brothers, and problems with her interpersonal relationships at the facility. On the protective side, Ms. Daniel currently has a regular sleep cycle. She is intelligent and was able to earn a medical degree and work as a pediatric doctor. She was able to avoid hospitalization for almost 45 years, so she must have had some effective coping mechanisms in place.

Assessing for additional strengths in Ms. Daniels
1. How was Ms. Daniels able to avoid hospitalization for almost 45 years? What coping mechanisms did she drew upon to achieve this?
2. How does Ms. Daniels manage to cope with all she’s been through?
3. When has Ms. Daniels felt well and able to function satisfactorily? What was she doing at those times? What supports did she have in place?
4. How would Ms. Daniels describe her future without her current mood problems? What would she be doing? With whom would she be spending time? How would she like to interact with others? Does she ever experience those preferences now?
5. What lessons has Ms. Daniels learned over the course of her life? What is she most proud of? What would she say to a young woman starting out today that was in the same position as her?

Intervention Plan
Goal #1: The client will maintain stable moods without manic or depressive fluctuations. The client will use psychotropic medications as prescribed by the ALF physician, meet weekly with the social worker for cognitive therapy to correct negative thinking patterns related to the course of her bipolar disorder, and complete a Depression Inventory weekly to assess level of functioning and overall depression level

Goal #2: The client will maintain a stable physical status, by using medications as prescribed for her physical conditions, meeting with the agency physician regularly for a health status review, and receiving a monthly monitoring of her thyroid function to prevent adverse effects from the lithium prescription.

Goal #3: The client will develop and utilize new interpersonal skills that promote more positive relationships with others. This will be accomplished through weekly meetings with the agency social worker based on interpersonal therapy to develop insight into negative pattern of thinking with respect to the lives of others and insight into the nature of her negative relationships.

Critical Perspective
This client appears to have a mood disorder as evidenced by her long history of depressive and manic episodes (by self-report) that have significantly interfered with her social and occupational functioning. The precise nature of her mood disorder is not clear, however, and may be difficult to clarify because she received many interventions prior to the introduction of lithium in the United States, and prior to psychiatry’s current level of understanding about bipolar disorder. She is adamant that mood swings have always been an issue for her, but she also speaks more generally about “anxiety”. Since some of her symptoms may have remitted it is difficult to identify her primary diagnosis with certainty. This case provides a good example of the difficulty of clear diagnosis without adequate access to an adult client’s prior history. Still, the client has responded well to lithium so bipolar disorder appears to be the appropriate diagnosis.

Answer 1

This is an issue for further exploration. Her tendency to (inaccurately) sense death in others could be a reflection of her own fears of aging. However, the client has little insight into this possibility. She does seem to feel that her life has no purpose, and her sadness about that may be reflective of difficulties with the adjustment to aging.