Question

Case Study: Mrs. X

MRS. X is a 47-year-old Caucasian female who presented with the chief complaints, “I just can't sleep no more. Nobody can talk to me—I bite their heads off! I don't want to be around nobody; they all get on my nerves. I've gotten to where I just keep to myself. I don't go anywhere, and I don't do anything. My mother tries to get me to come out of my room, but I just want to stay in bed and watch TV all day.” MRS. X reports losing her job as a retail sales associate two months ago after getting into an argument with her supervisor about product placement, “It was stupid. I even knew she was right, but the way she told me to arrange the shelf pissed me off. Most days I could deal with her attitude…I don't know what happened. I just snapped.”

Unable to pay her rent, MRS. X moved in with her mother last month. Her inability to support herself contributed to MRS. X's feelings of worthlessness and left her with little motivation to seek employment. Despite reporting a decreased appetite, MRS. X stated she had difficulty fastening her pants now, explaining, “I stopped walking like I used to. I just don't have any energy anymore.” Assessment revealed persisting low mood, increasing levels of agitation, anhedonia, and difficulty concentrating. By her own account, MRS. X also suffered decreased motivation, low energy, insomnia, feelings of worthlessness, agitation, and irritability. Her symptoms began nine months ago, when her only son was sentenced to ten years in prison on a drug related conviction. Out of financial necessity, his girlfriend and their 3-year-old daughter will soon be joining MRS. X in her mother's home, and MRS. X anticipates increased stress upon their arrival, “I've never liked her.”

MRS. X reports a history of using roughly one half gram marijuana two to three times weekly, “to take the edge off and help me to sleep.” She does not drink alcohol or use other drugs. MRS. X denies a history of psychotic symptoms and denies ever attempting to kill herself or having a history of psychiatric inpatient admission. She reports having thoughts recently of “just not being here,” but denies having specific plans of harming herself or of intent to do so. Assessment revealed no history of manic episodes, but careful inquiry exposed hypomanic episodes, beginning in her early 20s, during which MRS. X described herself as unusually productive, creative, and sociable, and “able to go all day and night on 3 hours sleep.” During such episodes, MRS. X experienced her only encounters with law enforcement, two speeding tickets, each received for going over twenty miles an hour over the respective posted legal limits. MRS. X states she enjoys shopping and has “gotten into trouble with credit cards a few times.”

MRS. X reports intermittent treatment of depressive symptoms since her early 20s, typically provided by her primary care provider, but on occasion by her gynecologist. She has either been treated with monotherapy antidepressants or a combination of antidepressant and benzodiazepine. She states that both of her traffic citations were received while she was on fluoxetine therapy. Upon reflection, MRS. X realized that most of her spending sprees occurred during periods of treatment, as well. Her treatment history also includes trials of sertraline, citalopram, venlafaxine XR, and bupropion. MRS. X reports modest improvement of negative mood symptoms with monotherapy of these antidepressants, which were, at times, supplemented with diazepam or lorazepam. MRS. X has also received trazodone treatment for insomnia, which she reports as effective in the past. MRS. X last received treatment for her mood symptoms three years ago. She states that she has not been compliant with treatment for longer than five or six months because the treatment she received either did not seem to help her depression or she felt so good that she believed herself to be well.

MRS. X's medical history is significant for hypothyroidism, seasonal allergies (golden rod in the fall, pollen in the spring, cut grass in the summer), osteoarthritis, and hypertension. Current medications include levothyroxine 0.75 mg daily, lisinopril 10 mg daily, hydrochlorothiazide 12.5 mg every morning, and celecoxib 200 mg daily. MRS. X's surgical history includes a total hysterectomy at age 37, secondary to menorrhagia related to fibroid tumors and a tonsillectomy at age 2, secondary to recurrent tonsillitis and ear infections. She is allergic to penicillin and quinolones (urticaria with each).

MRS. X's family mental illness history is positive for bipolar disorder (maternal grandmother, sister), anxiety disorder (mother), and attention deficit hyperactivity disorder (son, who also suffers from depression). No one in MRS. X's family has been admitted for inpatient psychiatric care or psychiatric admission. There is a significant family history, however, of substance use disorder, including tobacco (maternal grandmother, both paternal grandparents), alcohol (maternal grandmother, both grandfathers, father, mother, sister, and son), cannabis (father, brother, and son), and methamphetamine (son).

Questions

1.What is your diagnosis for Mrs. X? Use information from DSM-5. Provide evidence for your answers by stating why you have made this diagnosis.

2.In your clinical opinion, do you think Mrs. X has the potential to commit suicide? Why or why not? Explain your answer using concepts and theories? and What are the possible treatment options for Mrs. X, given information about her case?

Answer 1

1. The diagnosis for Mrs. X would be biploar disorder. According to the DSM 5, all those who meet the criteria for a bipolar disorder include the following symptoms- A distinct period of abnormally and persistently elevated, or irritable mood along with with and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. this is also followed by depressive episodes where one cannot get out bed and doesn't have the energy to engage in menial tasks also.

As we read her case history, all these symptoms can be seen in her.

-Irritability while engaging and conversing with other people around her.

-She had been consuming anti depressants in her medication course.

-Also engages in substance abuse, a few days in the week and suffers from insomnia due to all the energy she might have during her manic episode.

2. Mrs. X has mentioned that she has no plans to harm herself and die by suicide but she also thinks of times when she just does not exist anymore which could be considered a red flag and might lead to an act of self harm in the future which is why it's important to keep the individual under observation and it should be made sure that she's given the right medication and that she continues to take it.