Wasson_B_SamCaseStudy

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BENCHMARK CASE PRESENTATION 1 Benchmark Case Presentation Assignment Brittany N. Wasson School of Behavioral Sciences, Liberty University Author Note Brittany N. Wasson I have no known conflict of interest to disclose. Correspondence concerning this article should be addressed to Brittany N. Wasson Email: bnwasson@liberty.edu

Benchmark Case Presentation2 Case Study: Sam Client Concerns Symptoms Behaviors Stressors Worthlessness Thoughts of suicide, negative self-talk School difficulties, writing a book, internship Manic Mood swings, hearing voices Graduate School, lack of sleep, worried about being kicked out of her school program Depressed Suicidal thoughts, staying in bed all day Afraid to be honest with her family about her difficulties, family history of depression, worried about here future Insomnia Fatigue, Trouble sleeping Worries about school and writing her book Key Issues The client is unfortunately experiencing many difficulties, resulting in several key issues. The issues Sam is facing are biological, psychological, social, and spiritual, which is resulting in depression, manic episodes and overall sadness due to many stressors in her life. Biological The client states that she experiences restlessness and lack of sleep. She has many days where she also oversleeps and may become lethargic. She has days of extreme sadness and depression. Psychological The client has reported feeling worthless and depressed, along with overwhelming sadness. She hears voices in her head, giving her negative thoughts and how she is not a good writer. She also thinks about what life may be like if she never wakes up from her sleep. Social

Benchmark Case Presentation3 The client’s roommate has stated that she can not handle here constant mood swings and the manic episodes and has taken her and given her advice to seek help. Her roommate has also expressed that she has become difficult to live with. The client worries that these issues may hinder the relationship between her and her roommate. She has also been keeping her difficulties from her family and does not want to tell them the truth. The client states that she is not in relationship and has dated off and on. Spiritual The client has stated that she comes from a Catholic background and attended mass every week until she began graduate school. She no longer attends mass, but her faith and God are still very important in her life and would like to integrate this into her therapy. Assessment The client dealing with many stressors in her life, which has led to symptoms similar to Bipolar II disorder and possible Major Depressive Disorder (Mild) with mood- congruent psychotic features (F33.0). Due to the severity of the client symptoms, I would first like to gain a good relationship with the client since she has difficulties seeking help and being honest and open with those around her. Due to the multiple symptoms, she has, I would administer the MDQ (Mood Disorder Questionnaire), along with The Beck Depression Inventory due to the client vocalizing her concerns with depression and sadness along with here other symptoms. The MDQ has shown to be simple enough for all clients and studies have shown positive diagnosis outcomes (Wang et al. 2015). My main focus with this client is to assess the most difficult symptoms she is dealing with, and both of these assessments will target them. After the results of the tests, I can work to figure out where the root of issues lie and then focus on any of the secondary issues that also have an affect on the client.

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Benchmark Case Presentation4 Diagnostic Impression The client’s symptoms are consistent with Bipolar II Disorder, Moderate, with Psychotic features (F31.81). Signs and Symptoms DSM-5-TR Diagnostic Criteria: Bipolar II Disorder F31.81 Client’s Signs/Reported Symptoms: Criterion A: A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day nearly every day. Client’s roommate states that her mood swings were intolerable. Client also stays awake for hours, with little sleep and an abundance of energy, sometimes lasting 12 days with only 1-2 hours of sleep. Criterion B: During the period of mood disturbance and increased energy and activity, three (Or more) of the following symptoms have persisted (four if the mood is only irritable), represent a noticeable change from usual behavior, and have been present to a significant degree: 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep 3. More talkative 4. Subject experience of thoughts/ideas racing 5. Distractibility 6. Increase in goal-directed activity or psychomotor agitation, or 7. Excessive involvement in activities that have a high potential of painful consequences Client’s roommate has stated how she boasts about being the most significant author to have ever lived. Sometimes the client gets little to no sleep for long periods of time. Roommate states the client with talk nonstop about how phenomenal of an author she is. The client stays awake and writes her novel and screenplay, causing major fatigue and irritability. Criterion C: The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic The client was committed and motivated to her school program and became careless and unmotivated over time causing detrimental affects to her success in the program.

Benchmark Case Presentation5 Criterion D: The disturbance in mood and the change in functioning are observable by others The client’s roommate has observe manic behavior and change in her moods. Criterion E: The episode is not severe enough to cause marked impairment in social or occupational or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. The client was taken to the hospital for her manic episodes, but was not severe enough to be hospitalized. Criterion F: The episode is not attributable to the physiological effects of a substance of abuse or another medical condition The client has no diagnosis of mental disorders and has recently been put on medication, which she does not take. Other DSM-5-TR Conditions Considered Due to symptoms of depression, irritability, lack of energy, and thoughts of suicide, Major Depressive Disorder (Mild) with mood-congruent psychotic features (F33.0) was also considered. The client did not have a depressed mood most of the day, nearly every day, markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day and others. She experienced four of the nine symptoms. Developmental Theories and/or Systematic Factors The client is in Erikson’s sixth stage of development, Intimacy vs. Isolation. During this time, adults are looking for intimate and meaningful relationships. Due to the client’s difficulties and the stressors in her life with school, her novel and screenplay writing, she has not developed any close intimate relationships (Bishop et al. 2013). Instead of intimacy, the client is dealing with isolation due to all the situations she is going through. Systemic factors also have a role in her behavior due to here family also suffering from psychological issues, suicidal

Benchmark Case Presentation6 thoughts, poor performance at school, and distant relationships with her family and a strained relationship with her roommate. Multicultural and/or Social Justice Considerations The client did not state about any cultural or social justice influence, or relatable statements that could put these considerations into play. Treatment Recommendations Key Issues for Treatment  Depressed  Manic  Worthlessness  Insomnia Recommendations for Individual Counseling The client would do best, based on her symptoms, partaking in IPSRT (Interpersonal and Social Rhythm Therapy and also CBT (Cognitive Behavioral Therapy). ISPRT targets the changes in daily routines and the burden it has on the sleep regulation system, which can affect mood, and energy. This therapy works to establish a daily routine for sleep, wake, meals and daily activities to improve circadian and social rhythms, which has shown to be effective in Bipolar II disorder (Hoberg et al. 2013). CBT has been shown help relieve symptoms, stabilize moods and lower relapse rates for Bipolar Disorder (Chiang 2017). Specific Considerations Due to the client’s stress, there is a possibility of the client terminating treatment and therapy, which could compromise her recovery. She is currently in a very distraught and

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Benchmark Case Presentation7 unstable state of mind, that could change at any given moment. The first concern is the client’s safety and educating her on a crisis, deescalating, and providing resources once the client is stable and calm. Providing treatment and diagnosis at this time is not ideal and could be detrimental to the recovery process.

Benchmark Case Presentation8 References Bishop, Christopher & Keth, kenneth. (2013). Psychosocial Stages of Development. 10.1002/9781118339893.wbeccp441. Chiang KJ, Tsai JC, Liu D, Lin CH, Chiu HL, et al. (2017) Efficacy of cognitive-behavioral therapy in patients with bipolar disorder: A meta-analysis of randomized controlled trials. PLOS ONE 12(5): e0176849. https://doi.org/10.1371/journal.pone.0176849 Hoberg AA, Ponto J, Nelson PJ, Frye MA. Group interpersonal and social rhythm therapy for bipolar depression. Perspect Psychiatr Care. 2013 Oct;49(4):226-34. doi: 10.1111/ppc.12008. Epub 2013 Jan 18. PMID: 25187443; PMCID: PMC4156105. Wang, H. R., Woo, Y. S., Ahn, H. S., Ahn, I. M., Kim, H. J., & Bahk, W. M. (2015). THE VALIDITY OF THE MOOD DISORDER QUESTIONNAIRE FOR SCREENING BIPOLAR DISORDER: A META-ANALYSIS. Depression and anxiety , 32 (7), 527– 538. https://doi.org/10.1002/da.22374

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