Case Report

Patient Name: George Lawler

DSM-5 Diagnosis:
Principle Diagnosis: Bipolar I Disorder, most current episode manic, severe (296.43)
V62.29 - Other Problem Related to Employment
V15.42 – Personal history (past history) of psychological abuse in childhood

Justification for Diagnoses:

Bipolar I Disorder, most current episode manic, severe (296.43):
George Lawler is a 35-year-old married male, father of two children, and gainfully employed for
several years at a local Junior College’s kinesiology department. George is responsible for
coaching both the men’s and women’s track teams, and for departmental administrative
functions. Although the competitive winnings at that Junior College were not significant in the
years before George was hired, the athletes have now been enjoying a turnaround of that losing
trend. This year, George’s teams have been undefeated, and are the anticipated forerunners to
win at the upcoming Conference Championship. Because of such success, George’s teams’
athletic competitive statistics are being very closely followed, which has increased the pressure
on George and the department’s student athletes to continue to perform at a high level. It was
reported by his wife at the time of his hospitalization that over the course of the preceding 2
weeks, George’s mood at home has become increasingly irritable due to, what she believes to be
the increase of pressure at work. George’s wife reports that he has become hyper-focused on
work-related issues which have caused George to increase the number of hours he spends daily
at work in his office (Appendix A).
George had been awake for a period of 3 nights at the time of hospitalization. Upon admission,
he was observed talking incessantly, almost to the point of harassing other patients and staff.
Psychomotor agitation was observed in George’s erratic movements. He was observed pacing up
and down the halls of the ward as he explored every single room, and at one point attempted to
enter a restricted area of the unit. When his entry to the restricted area was blocked, his reaction
was an explosion of anger. George’s response to the blocking of his entry into a restricted area
of the hospital ward would be considered atypical for a person of equal intellectual and cognitive
development. George was overheard claiming to be the coach for the US Olympics Team and
that he would be holding “tryouts for … [his] teams”. These statements are indicative of an
inflated self-esteem. It is through his verbose grandiosity that his behavior meets the criteria for
that of a delusional level of psychosis (criterion C1) within the manic state he is concurrently
experiencing. A phenomenology exists for George wherein he currently believes his role in life
is at a higher echelon than it actually is. The reality of George’s professional employment
capacity is that of a mid-level coach at a small junior college. A history of losses in the
competitive collegiate circuit of sports prior to George’s arrival in the department was the reality
in which George had entered when he was initially hired. Over time, it was his successful
coaching style and the athletic talent recruited by the junior college which improved,
competitively, the status of the department to a level higher than that of previous years.
However, the winnings achieved by the athletic department, George, and his roster of competing
student athletes do not compete at the level of US Olympics. George is currently displaying signs
and symptoms of a delusional episode; his delusion is part of in his current manic state.
George has at least 2 additional manic episodes over the course of his lifetime (criterion A-D).
While those episodes of mania experienced while in young adulthood were viewed as hypomanic
at the time, the eventual necessitation of hospitalization due to manifestations of increasing
severity of symptoms are the criterion which culminate to render the diagnosis specifically be
that of bipolar I with manic episodes, severe, and depressive episodes, with mixed features. From
a biological model perspective, George’s bipolar I disorder with manic episodes and depressive
episodes, with mixed features may be the result of biological scarring, considering his age at the
onset of the disorder. Any structural abnormalities in George’s brain are currently unknown and
would require further neuroimaging testing, (i.e., CAT, PET, MRI, or fMRI) to either rule out or
confirm the existence of any structural brain abnormalities as there is no indication that any type
of neuroimaging has been performed. There does exist, however, substantiated medical history
from George’s maternal lineage which indicates the presence of bipolar disorder in that of
George’s first-generation relative, an Uncle. The presence of bipolar disorder in this relative
substantially increases the likelihood of George’s inheritance of the disorder. The medical
records retrieved by the family indicate a diagnosis of “Acute Schizophrenic Reaction”, but this
antiquated terminology would be viewed as a misdiagnosis according to the criteria in the DSM-
5, as the family member’s symptoms would currently meet the threshold for that of a diagnosis
of bipolar I disorder.
An incident of note in which one of George’s manic episodes was severe enough for him to be
involuntarily committed to a psychiatric hospital for three days of observation also contributed to
George’s diagnosis. The incident involved his wife, Cheryl, being unable to locate George for
several hours and after much effort, was able to locate him in his office experiencing a severe
manic episode. Cheryl was unable to convince George that he needed help, despite her
profession being in the field of psychology, and took it upon herself to notify the police. After a
court hearing, a Judge compelled George into involuntary commitment to a psychiatric hospital
due to the fears of George harming himself or others.
George’s most recent depressive episode occurred 8 months prior, in the month of September, to
his current hospitalization. It was in the summer months preceding the upcoming fall semester in
which George began to experience acute levels of anxiety related to his work functions and the
anxiety increased in severity over time. In addition to anxiety, ruminating thoughts linked to
work related issues, insomnia, and fatigue were all comorbid (criterion A). The unexpected
departure of a colleague from the department and the denial of expected additional departmental
funding led to George experience excessive feelings of guilt and worthlessness (criterion A &
C). Cognitive distortions triggered both a catastrophizing and a personalization of these
happenstances and were completely unrelated to George’s personal work performance. The
diathesis-stress model of abnormal behavior, which assumes a comorbidity of depression was
preexisting and dormant, then triggered by the listed set of psychosocial stressors are
components which contributed to the onset of the current manic episode he is experiencing.
His increasingly depressed mood was clearly observed by other family members who also noted
a diminished interest in most of his home and work activities. Severe psychomotor retardation,
almost to the point of catatonia were observed. Feelings of excessively inappropriate guilt and
worthlessness eventually led George to suicidal ideations in which he threatened to, “[…] end it
all if his family would only leave [me] him alone” (criterion A-C). George has no personal
history of known drug or alcohol abuse whether in childhood, adolescence, or adulthood
(criterion B). It should be noted that although George does display a propensity to embrace
traditional gender roles, he does have a strong interpersonal support network in that of his wife,
Cheryl. On multiple occasions Cheryl has made significant efforts to seek out treatment for
George both in the form of traditional therapy, hospitalization, and psychopharmacology. With
the known familial history of a first-degree relative, George’s Uncle, who was diagnosed with
antiquated disorder terminology which is no longer recognized by the DSM-5. Memorialized in
records as an “acute schizophrenic reaction”, more than likely a diagnosis of bipolar I disorder
according to the diagnostic criteria of the DSM- 5 would be assigned. George’s genetic
predisposition of the propensity to inherit bipolar disorder is 2 to 3 times higher than average to
occur. Suffering from the symptoms of a recurrence of depression are increased as well, due to
his early age at the onset of the bipolar I disorder.

General Medical Conditions: George Lawler has been diagnosed with bipolar disorder in late
adolescence / early adulthood. It is George’s only known preexisting condition at the time of this
report. Maintenance doses of lithium carbonate prescribed to Gorge were effective as a treatment
and successful suppression of manic and depressive symptoms which were stabilized for an
unknown length of time. It is unknown if George is currently compliant with any prescription
orders which may exist at the time of his most recent manic episode.

Other Problem Related to Employment (V62.29):

George was hired to coach both the men’s and women’s track track teams in the athletic
department of a Junior College whose record of unsuccessful competitive winnings in previous
years had become the trend. Over the course of George’s employment, his successful coaching
style brought about a closer scrutiny of both his work performance and the athletic department's
increased athletic conference competitive winning statistics. A set of additional psychosocial
stressors contributed to the onset of George’s most recent manic episode. Those incidents
included a distinct set of professional disappointments: the denial of additional expected funding
for the Athletic Department, and the loss of a departmental colleague whose choice to return to
college in order to finish their degree was not the result of George’s professional performance in
any way. However, this psychosocial stressor produced cognitive distortions in the form of
personalization of a situation, one which was completely beyond his control, and let to George’s
catastrophizing of the overall situation.

Personal History (past history) of Psychological Abuse in Childhood (V15.42):

Although described as “unremarkable,” George’s childhood may be significantly affected by the
behavior and addictions of his Father. George’s Father was also a coach, but at the high school
level. It may be that George felt the need to to impress or live up to his Father’s standards,
whether real or imagined, which in-turn manifested itself as work-related, professional attempts
at overachievement, in some way. This may account for his slightly higher employment status
and need, drive, or desire for professional perfection and athletic winnings in his adult life.
George’s Father was an alcoholic when George was a child. This psychosocial stressor may have
contributed to a form of psychological abuse to George in his childhood.
Recommended Treatment Plan:
The recommended treatments for George should begin with assessing an appropriate dose of a
mood stabilizing medication to combat manic episodes experienced by George. Lithium
Carbonate has been successful in treating George’s manic episodes in the past; however, it has
been known to cause lethargy and other negative side effects for some people. Due to the
severity of mania experienced by George, as well as its known efficacy, it is my recommendation
that George’s treatment begin with doses of lithium carbonate. Should George be resistant or
reluctant to take lithium carbonate, (e.g., if he indicates it worked before, but stopped taking it
for whatever reason) I would recommend an atypical second-generation antipsychotic such as
aripiprazole (Abilify) to combat George’s manic episodes in conjunction with another ASG
medication, Lurasidone (Latuda), which should address depressive symptoms or episodes for
George.
Medication alone will not be sufficient treatment for successful management of the symptoms of
George’s diagnosis of bipolar I disorder. A combination of ASA medications can effectively
regulate hormonal imbalances in the brain and should be a primary component in George’s
treatment regimen for bipolar I, but additional psychotherapies are necessary in order to treat the
“whole person” – that is the mind and body, along with George’s family members. Cognitive
Behavioral Therapy (CBT) should be held as a therapeutic treatment, working in tandem with the
appropriate and regular medication dosing so that George may, over time, develop the ability to
use behavioral strategies in an effort to help George recognize the onset of manic or depressive
symptoms and signs of any impending mood shifts. CBT will allow George to reduce the risk of
rehospitalization and should improve his ability to function interpersonally with co-workers and
family members.
Other Treatment Recommendations:
The use of hypnosis has been extensively studied and statistical data has shown that people who
have a diagnosis of bipolar I and II respond to the process of hypnosis with a higher degree of
suggestibility, the theoretical component of hypnosis through which hypnotic treatments are
administered. In a study published in the Journal of BMC Psychiatry titled, “Hypnotic
susceptibility and affective states in bipolar I and II disorders”:

Bipolar Disorder I patients followed motor suggestions more often, unlike cognitive
suggestions, under hypnosis, while both bipolar disorder patients and healthy volunteers
demonstrated an association between mania levels and certain hypnotic susceptibility
features. Our findings contribute to the understanding of emotional, cognitive and
behavioral alterations in bipolar disorder patients, and encourage the incorporation of
related psychotherapy in their treatment. (Appendix B)

When incorporated into a consistent therapeutic regimen of medication and CBT therapy,
hypnosis can be used as a peripheral treatment to specifically address psychosocial stressors,
such as coping with and managing anxiety experienced at work (e.g., the stress related to a
colleague leaving George’s department unexpectedly). George has experienced stress and
anxiety-induced mania tied to these events. These types of issues are those which hypnosis is
designed able to address by way to the subconscious mind; a high probability of efficacy,
stemming from the theory of high suggestibility in people diagnosed with bipolar disorder,
through hypnosis is suggested as a co-therapy set in place to prevent future manic or depressive
episodic events.
Although George has been hospitalized on more than one occasion in his lifetime, I would not
immediately recommend that George seek electroconvulsive therapy as a treatment for his
diagnosis of bipolar I disorder at this time. George’s history seems to indicate more manic
episodes than depressive episode, and although he has experienced at least one severe depressive
episode, George’s disorder tends to exhibit more extreme (severe) and frequent episodes of
mania than it does severe depressive episodes. ECT therapy could be considered should George
continue to experience prolonged periods of severe mania or severely debilitating depressive
episodes, but only if the pharmacotherapy, CBT therapy, and / or other therapies (e.g.,
hypnotherapy) are not efficacious. It would be only that that time that ECT treatments should be
considered as a treatment for his symptoms of bipolar I disorder.

Underlying Theoretical Explanations:

Using a biopsychosocial model as the etiological foundation of George Lawler’s primary
diagnosis of bipolar I disorder that his diagnosis can be concluded. The contributing factors
leading to George’s diagnosis by applying a biopsychosocial model also include a diathesis-
stress model of abnormal behavior which is believed to play a concurrent role in the
manifestation of George’s manic and depressive episodes. It is through the combination of these
two models that the etiology of George’s disorder is most accurately diagnosed. Reviewing the
familial predisposition for inheritance of bipolar disorder, due to its presence in a first-degree
family member, an Uncle, his genetic predisposition to inherit bipolar disorder was also taken
into consideration. Through the scrutiny of George’s familial medical history, outwardly
displayed symptoms and behaviors, both at the time of his most recent and current episode and
over the course of his lifetime, as well as his socioeconomic status, sex, race, and level of
education are the totality of underlying symptoms and causations through which a
biopsychosocial model as the etiology for his diagnosis of bipolar I disorder was determined.

Diagnostician: ANONYMOUS Date: October 9, 2020

 Appendix A
Bipolar I Disorder:
A. Criteria had been met for at least one manic episode (criteria A-D under “Manic
Episode” below).
B. The occurrence of the manic and major depressive episode is not better explained by
schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional
disorder, or other specified or unspecified schizophrenia spectrum and other
psychotic disorder.
Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable
mood and abnormally and persistently increased goal-directed activity or energy,
lasting at least 1 week and present most of the day, nearly every day (or any duration
if hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or
more) of the following symptoms (four if the mood is only irritable) are present to a
significant degree and represent a noticeable change from usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only three hours of sleep)
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant or
external stimuli), as reported or observed.
6. Increase in goal-oriented activity (either socially, at work or school, or sexually)
or psychomotor agitation (i.e., purposelessness non-goal-directed activity).
7. Excessive involvement in activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions,
or foolish business investments).
C. The mood disturbance is sufficiently severe to cause marked impairment in social or
occupational functioning or to necessitate hospitalization to prevent harm to self or
others, or there are psychotic features.
D. The episode is not attributable to the psychological effects of a substance (e.g., a drug
of abuse, medication, other treatment) Or to another medical condition.
Note: A full manic episode that emerges during antidepressant treatment (e.g.,
medication, electroconvulsive therapy) but persists at a fully syndromal level beyond
the psychological effect of that treatment is sufficient evidence for a manic episode
and, therefore, a bipolar 1 diagnosis.
Note: Criteria A-D constitute a manic episode. At least one lifetime manic episode is
required for the diagnosis of bipolar 1 disorder.

The above diagnosis is Reprinted with permission from the American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American
Psychiatric Association; 2013:124-126, 149-150
 Appendix B

Zhang, B., Wang, J., Zhu, Q., Ma, G., Shen, C., Fan, H., & Wang, W. (2017). Hypnotic
susceptibility and affective states in bipolar I and II disorders. BMC psychiatry, 17(1), 362.
https://doi.org/10.1186/s12888-017-1529-2

The above diagnosis is Reprinted with permission from the American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American
Psychiatric Association; 2013:124-126, 149-150