Elisabeth Jacks Case Study Bipolar I Disorder
Elisabeth Jacks Case Study Bipolar I Disorder
Elisabeth Jacks Case Study Bipolar I Disorder
Elisabeth Jacks ran a catering service with her second husband, Donald, the main informant.
At age 38, Elisabeth already had two grown children, so Donald could understand why this pregnancy might have upset her. Even so, she had seemed unnaturally sad.
From about her fourth month, she spent much of each day in bed, not arising until the afternoon, when she felt less tired. Her appetite, voracious during her first trimester, fell off so that by the time of delivery, she was several pounds lighter than usual for a full-term pregnancy.
She had to give up keeping the household and business accounts because she couldn’t focus her attention long enough to add a column of figures. Still, the only time Donald became alarmed was one evening at the beginning of Elisabeth’s ninth month, when she told him that she had been thinking for days that she wouldn’t survive childbirth and he would have to rear the baby without her. “You’ll both be better off without me, anyway,” she had said.
After their son was born, Elisabeth’s mood brightened almost at once. The crying spells and the hours of rumination disappeared; briefly, she seemed almost her normal self. Late one Friday night, however, when the baby was 3 weeks old, Donald returned from catering a banquet to find Elisabeth wearing only a bra and panties and icing a cake.
Two other just-iced cakes were lined up on the counter, and the kitchen was littered with dirty pots and pans.
“She said she’d made one for each of us, and she wanted to party,” Donald told the clinician. “I started to change the baby—he was howling in his basket—but she wanted to drag me off to the bedroom. She said ‘Please, sweetie, it’s been a long time.’ I mean, even if I hadn’t been dead tired, who could concentrate with the baby crying like that?”
All the next day, Elisabeth was out with girlfriends, leaving Donald home with the baby. She spent nearly $300 on Christmas presents on Sunday at an April garage sale. She seemed to have boundless energy, sleeping only 2 or 3 hours a night before arising, rested and ready to go. On Monday, she decided to open a bakery; by telephone, she tried to charge over $1,600 worth of kitchen supplies to their Visa card. She’d have done the same the next day but talked so fast that the person she called couldn’t understand her. In frustration, she slammed the phone down.
Elisabeth’s behavior became so erratic that for the next two evenings, Donald stayed off work to care for the baby, but his presence only provoked her sexual demands. Then there was the marijuana. Before Elisabeth became pregnant, she would have an occasional toke (she called it her “herbs”). During the past week, not all the smells in the house had been fresh-baked cake, so Donald thought she might be at it again.
Yesterday Elisabeth awakened him at 5 A.M. and announced, “I am becoming God.” That was when he made the appointment to bring her for an evaluation.
Elisabeth herself could hardly sit still during the interview. In a burst of speech, she described her renewed energy and plans for the bakery. She volunteered that she had never felt better in her life. In rapid succession, she then described her mood (ecstatic), how it made her feel when she put on her best silk dress (sexy), where she had purchased the dress, how old she had been when she bought it, and to whom she was married at the time.
Patients who may have bipolar I disorder need a careful interview for symptoms of addiction to alcohol; alcohol use disorder is diagnosed as a comorbid disorder in as many as 30%. Often alcohol-related symptoms appear first.
Elisabeth Jacks Case Study Bipolar I Disorder
This vignette provides a fairly typical picture of manic excitement. Elisabeth Jacks’ mood was elevated. Aside from the issue of marijuana smoking (which appeared to be a symptom, not a cause), her relatively late age of onset was the only atypical feature.
For at least a week, Elisabeth had had this high mood (manic episode criterion A), accompanied by most of the other typical symptoms (B): reduced need for sleep (B2), talkativeness (B3), flight of ideas (a sample run is given at the end of the vignette, B4), and poor judgment (buying Christmas gifts at the April garage sale—B7).
Her disorder caused considerable distress for her family if not for her (C); this is usual for patients with manic episodes. The severity of the symptoms (not their number or type) and the degree of impairment were what would differentiate her full-blown manic episode from a hypomanic episode.
The vignette does not address the issue of another medical condition (D). The admitting clinician would have to rule out medical problems such as hyperthyroidism, multiple sclerosis, and brain tumors before a definitive diagnosis. Delirium must be ruled out for any postpartum patient, but she was able to focus her attention well.
Although Elisabeth may have been smoking marijuana, misuse of this substance should never be confused with mania; neither cannabis intoxication nor withdrawal presents the combination of symptoms typical of mania.
Although the depression that occurred early in her pregnancy would have met the criteria for major depressive episodes, her current manic episode would obviate major depressive disorder.
Because the current episode was too severe for hypomanic symptoms, she could not have the cyclothymic disorder. Therefore, the diagnosis would have to be bipolar I disorder (because she was hospitalized, it could not be bipolar II). The course of her illness was not compatible with any psychotic disorder other than brief psychotic disorder, and that diagnosis specifically excludes bipolar disorder (B).
The bipolar I subtypes, as described earlier, is based on the nature of the most recent episode. Elisabeth’s, of course, would be the current episode manic.
Next, we’ll score the severity of Elisabeth’s mania (see the footnotes in Table 3.2). These severity codes are satisfactorily self-explanatory, though there’s one problem: Whether Elisabeth was psychotic is not made clear in the vignette. If we take her words literally, she thought she was becoming God, in which case she would qualify for severe with psychotic features. These would be judged mood-congruent because grandiosity was in keeping with her exalted mood.
The only possible episode specifier (Table 3.3) would be with peripartum onset: She developed her manic episode within a few days of delivery. With a GAF score of 25, the full diagnosis would be.
| F31.2 [296.44] | Bipolar I disorder, currently manic, severe with mood-congruent psychotic features, with peripartum onset |
