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Abnormal Psychology: Clinical Perspectives on Psychological Disorders Case Study
Chapter 7: Depressive and Bipolar Disorders
- Case Study: Janice Butterfield
- Demographic information: 47-year-old Caucasian female.
- Presenting problem: Janice was referred for psychotherapy after a recent hospitalization following a suicide attempt. Janice reported that the precipitant to her suicide attempt was the loss of her job in a real estate company, where she had worked for 25 years. She reported that although she realized her company had downsized due to the economy, she found herself feeling profoundly guilty for the negative impact her unemployment would have on her family. Janice reported she has been married for 27 years and has three daughters, one of whom lives at home. Another is in college, and her youngest will be attending college at the start of the next school year. Janice reported she had felt overwhelmed by the stress about her financial state, as her family mainly relied on her income. Along with feelings of guilt, Janice reported she had felt so depressed and down that she spent many days in the past 2 weeks in bed, and often found herself thinking of ending her life. She stopped taking pain medication, which was prescribed for her chronic backaches “to save up if I needed them later.” One evening when her husband was out of the house, she attempted suicide by taking all of her saved-up medications at once. Janice's husband returned to find her unresponsive and rushed her to the hospital just in time to save her life. She was hospitalized in an inpatient psychiatric unit and given medication until her suicidal thoughts and severe depression decreased enough so that the doctors deemed her no longer a threat to herself. She followed the referral given to her by the psychiatrists on the inpatient unit to attend weekly psychotherapy for follow-up. She had never been in therapy before. During her first therapy session, Janice reported that she had thought about going to therapy many times before. She explained that her depressions usually lasted about 1 month, but sometimes as long as 3 months. During these periods, she missed a few days of work but she was able to struggle through these periods and go about her normal routine albeit with much difficulty. During these periods, she would go out to her car to cry, because it would be too painful to be around others. “I just didn't want anything to do with life at those points,” she recalled. Her depression would eventually improve on its own, as well as her thoughts about getting treatment. She reported that she had occasionally thought about suicide in the past when she was feeling depressed, but had never before made and carried out a plan as she had during the most recent episode. Janice went on to explain how these depressed moods always caught her “off guard,” as they would occur directly after long periods when she felt happy and energetic. She stated these moods usually started after she had made a large real estate sale, and she felt “invincible” after such a sale. During these times, she described that she often needed very little sleep due to the seeming endless amount of energy she possessed, and she would begin to take on many new projects and clients at work—much more than would be expected of her. During these periods she splurged on lavish clothing or jewelry, and during her last energetic period had purchased new cars for herself and her husband. These expenditures were uncharacteristic for Janice, as she described herself as normally financially frugal. Due to her constantly moving thoughts, Janice found it very difficult to concentrate and was so distracted she was rarely able to finish anything she began to take on at work. She would feel disappointed that she had to give up some of her projects, and her joyful feelings would turn to irritability and anger. She reported that her husband usually experienced the brunt of her irritable mood, and this caused major problems in their marriage. Janice further reported that she felt like she ignored her family altogether due to her work habits when she was feeling particularly energetic. She remarked, “When I'm feeling that good, I can only think about myself and what feels good to me. I stop being a mother and a wife.” Her extreme spending periods eroded her family's savings, which was especially a concern now that she had lost her job. This also contributed to her guilt about paying for her youngest daughter's college tuition. Janice had never talked with her husband or her children about her vast mood shifts. She stated she worried that if she had told her family about her personal difficulties, they would “see me as a weakling, instead of the head of the household.”
- Relevant history: Janice had never received psychiatric treatment or therapy in the past, though she reported she had experienced mood swings since she was 19. She estimated that she had severe mood episodes (either manic or depressive) about three to four times per year. When reflecting about the severity of her mood episodes, she stated that she felt her behaviors had been more “extreme” in more recent years than when she was younger. Janice reported that she noticed the patterns in her mood swings always began with an energetic period, directly followed by a depressive episode, and then a period of several months of stability. More recently, though, she noted that the periods of stability had only been lasting 1 or 2 months, and her mood episodes had been lasting longer.
- Case formulation: Janice's diagnosis from the psychiatric unit was a Major Depressive Episode, and her current presentation also met this criteria. However, in the initial therapy session she reported also having a history of manic episodes that were followed by periods of depression, which she had not mentioned while she had been hospitalized. The manic symptoms she described caused significant problems for Janice financially, due to her excessive spending sprees. In combination with losing her job, her financial problems caused significant stress for Janice and may have contributed to the severity of her most recent depressive episode, which eventually led to a suicide attempt. Therefore, her diagnosis is Bipolar I Disorder, most recent episode depressed.
- Treatment plan: It is recommended that Janice continue to attend psychotherapy weekly. In therapy, it will be necessary to make a suicide safety plan, given her history of suicidal ideation in the past. Therapy should initially focus on psych education, symptom management, and mood monitoring. She will also be referred to an outpatient psychiatrist for medication reconciliation, as psychotherapeutic medication is highly recommended in the treatment of bipolar disorder.