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Diagnostic Case Study: Bipolar I Disorder
Mohamed Ali
Dr. László Lajtai
Faculty of Education and Psychology
ELTE University
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Table of Contents
Introduction...................................................................................................................................3
Bipolar I Disorder.........................................................................................................................3
Pre-Field.........................................................................................................................................5
Interviews.......................................................................................................................................6
First Interview...................................................................................................................6
Anamnestic Interview.......................................................................................................8
Third Interview.................................................................................................................9
Final Interview..................................................................................................................9
Diagnostic Assessment................................................................................................................10
Diagnostic Assessment Results...................................................................................................11
Proposed Diagnosis.....................................................................................................................12
Conclusion...................................................................................................................................14
References....................................................................................................................................15
Appendix......................................................................................................................................16
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Diagnostic Case Study: An Applied Thesis
Introduction
This diagnostic case study is concerned with a series of interviews that were conducted
by Mohamed Ali, the author and a clinical psychology student at ELTE University in Budapest,
Hungary, with an interviewee over Skype, a software used for communicating via both audio and
video. There were a total of four interviews conducted, and each interview lasted between 54 and
83 minutes, with an average of 66 minutes per interview. Since this is a diagnostic case study, a
total of three diagnostic tests were administered, and both the results and clinical interpretation
of these tests, in relation to the patient’s concerns and symptoms, is discussed in this paper.
Furthermore, the interviewee was informed regarding the purpose of this interview, the
general content of it, and the fact that the interview will be anonymized and encrypted in order to
protect the interviewee’s privacy and best interest. More importantly, the interviewee accepted
the aforementioned conditions and expressed his written consent concerning participating in this
interview. Finally, the virtual interviews were conducted in each of the participants’ homes
respectively, with the interviewer residing in Budapest, Hungary and the interviewee residing in
Tromsø, Norway.
Bipolar I Disorder
Bipolar I disorder (BD-I), less commonly known as manic-depressive disorder or manic
depression, is a mental illness with its own chapter in the DSM-V, along with similar illnesses,
such as cyclothymia (Müller-Oerlinghausen et al., 2002). A patient with BD-I will exhibit at
least one manic episode across their lifetime. A manic episode is a period of abnormally elevated
or irritable mood coped with high energy levels, and these are turn in accompanied by abnormal
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behavioral patterns that quite often disrupt proper daily functioning (Müller-Oerlinghausen et al.,
2002). Most patients with BD-I suffer from intermittent episodes of depression, as there is often
a cyclic pattern between mania and depression, hence the term manic depression. Nonetheless, in
between these cyclic patterns of mania and depression, BD-I patients may still be able to live a
normal life.
In regard to the onset of BD-I, virtually anyone can develop the disorder over the course
of their lifetime. In the United States, around 2.5% of the total population suffers from BD-I,
which translates into almost 6 million BD-I patients (Carvalho et al., 2020). Symptoms of BD-I
manifest during teen years or the early 20s, and nearly every patient with BD-I develops the
disorder before the age of 50, and patients have a higher risk of developing BD-I if they have an
immediate family member with the disorder. The symptoms of BD-I differ according to the
prevalent episode a patient is going through, which is either a manic or a depressive episode.
Depressive episodes in BD-1 display similar symptoms to those other depressive states, such as
that of clinical depression, but on the other hand, symptoms of manic episodes include, but are
not limited to, increased energy levels, inflated self-image, excessive spending, rapid speech,
hypersexuality, and substance abuse (Carvalho et al., 2020). In addition, during a severe manic
episode, a BD-I patient may entirely lose touch with reality, become delusional, and behave
bizarrely.
If left untreated, a manic episode may last anywhere from a few days to a few months,
but commonly, the symptoms continue for a few weeks to a few months. Afterwards, a
depressive episode may manifest, and sometimes, the onset of the depressive episode may not
appear for weeks or months (Müller-Oerlinghausen et al., 2002). Depressive episodes in BD-I
can last from weeks to months, but rarely longer than one year. While many BD-I patients
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experience long periods without any symptoms in between their episodic cycles, some patients
with the disorder exhibit rapid cycling symptoms of mania and depression, in which they
manifest episodes of mania or depression at least four times a year (Carvalho et al., 2020).
Similarly, a minority of BD-I patients may exhibit mixed episodes, where they simultaneously
display symptoms of both manic and depressive episodes, and may even alternate between both
episodes in the same day. Unfortunately, the causes of BD-I, as well as BD-II, are not well
understood, and thus, it is not known if the disorder can be entirely prevented. However, there
are a number of effective treatments for BD-I, including mood stabilizers, antipsychotics, and
benzodiazepines.
Pre-field
From here on after, the patient will be addressed through his initials, ‘B.H’, for the sake
of anonymity and confidentiality. B.H is a thirty-one year-old Norwegian male residing in
Tromsø, Norway. It is worth mentioning that, before the patient was referred to his current
mental health professional, his GP had reasonable doubt to believe that B.H suffered from a
personality disorder, with Borderline Personality Disorder (BPD) being a likely diagnosis. Thus,
the patient was referred to his current mental health professional, who in turn, after contacting
the patient, gave the interviewer permission to contact the patient and commence the diagnostic
case study. However, the patient’s current mental health professional advised the interviewer that
BPD was not a likely diagnosis, in contrast to what the patient’s GP stated earlier before the
referral, yet, this information did not affect the course of the diagnostic interviews and the case
study as a whole. Nonetheless, this information was taken into consideration when interviewing
B.H, but more importantly, when formulating the diagnosis for the patient. All the information
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mentioned in this section of the paper was presented to the interviewer before meeting B.H for
the first interview, and thus, were considered part of the pre-field assessment.
First Interview
The first interview conducted with B.H was a general, unstructured interview that
consisted of a number of open-ended questions that revolved around the patient’s childhood,
adulthood, upbringing, relationships, and current concerns. B.H is the only sibling to his parents,
who “have always enjoyed” their married life and consider themselves “quite lucky” to have
found each other. The patient recalls his childhood, until the age of 10, as being “generally
happy”, as he was performing well at school and was engaged in a lot of physical sports, to
which he thanked his father for, and B.H seemed content as he reminisced about his younger
days. Moving on, B.H mentioned that his problem, started after the age of 10, as he became
“hyperactive” during that time in his life, which consequently affected his school performance,
but had no effect on his performance in P.E and music class. The patient had trouble focusing in
class, and since he constantly was eager to leave school, he did not form any close relationships
with his school peers. And although B.H did not get into any trouble with his schoolmates, he
came across issues with his teachers in class, often because he “walked around” the class and
“interrupted” his teachers. Besides that, the patient does not remember much of this time in his
life.
After the age of 18, B.H had started to get into a fair amount of trouble, as the patient
then had started to experiment with some drugs, mostly amphetamines and cocaine, as they are
amongst the most popular drugs in Norway. In addition, the patient mentioned that around the
same time, his drinking had become problematic, as every weekend he would get into an
unfortunate incident, sometimes more than one, due to his alcohol-induced lack of control. The
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most problematic aspect of the patient’s alcohol abuse, since it was clear his consumption is not
recreational, manifested in his driving, as he would often drive back home under the heavy
influence of alcohol. In fact, at the age of 20, B.H had his license suspended for a whole year, as
he was caught not only driving under the influence, but also considerably above the speed limit.
Unfortunately, the patient’s erratic behavior also manifested in his sexual interactions. At the age
of 21, B.H impregnated a woman that he was “madly in love with”, and they both decided to
keep the child and even moved in together.
After two months of living together, B.H mentioned that he changed his mind regarding
the relationship, and sadly, the thought of being a father, and thus, he insisted that the woman
undergo an abortion, which she did after B.H managed to convince her. The patient mentioned
that, ten years later, he still “regrets” the circumstances that he got the woman into, but not the
abortion. Surprisingly, B.H mentioned that a similar scenario occurred again in his life, less than
two years later, where he impregnated another woman, but that she wanted to get an abortion on
her own since she was already in a relationship with another man. The longest relationship that
B.H has been in was his last relationship, which lasted a little bit less than a year. His past
relationship ended because he cheated on his partner with one of her best friends on new year’s
eve of the year 2020, and upon finding out, his partner kicked him out of the apartment that they
were living together in. B.H mentioned that his past relationship was not excellent either, since
him and his partner often got into heated arguments and were even verbally abuse towards each
other.
Over the past year, B.H lost his partner, albeit due to his own impulsivity and
carelessness, and is currently struggling financially. The patient’s financial struggles are due to
him losing his job recently in the oil sector in Norway. B.H used to work at an oil rig at sea,
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where he would spend two weeks at sea followed by four weeks at home, and he had the same
job for years and was satisfied with it. Unfortunately, B.H was fired from his job during the
COVID-19 pandemic, as his company was forced to cut down on expenses, which meant some
employees had to be laid off, yet, the patient believes that he was treated unfairly and that his
“loyalty to the company” was not rewarded. It is worth noting that the oil sector in Norway, even
prior to the COVID-19 pandemic, had not been performing well in light of the heightened
interest in renewable sources of energy. Thus, over the past year, B.H had lost his job and his
partner, but importantly, has reported having suicidal thoughts, which is the primary reason the
patient’s GP referred him to his current mental health professional.
Anamnestic Interview
This session was intended to dive deeper into the anamnestic information of the patient,
in an effort to not only familiarize with his concerns, but also to identify a set of diagnostic
criteria that the patient may or may not fit. The first half of the interview consisted of open-ended
questions as well, but in contrast to the first session, these open-ended questions were aimed at
the patient’s medical history and current mental health complaints, while during the second half
of the session the Mini International Neuropsychiatric Interview (MINI) (Sheehan et al., 1998).
During this interview, B.H had mentioned that he seldom struggled with anger issues, but often
faced challenges regulating his emotions, especially under the influence. Interestingly, B.H
suspects that he may have suffered from Attention Deficit Hyperactivity Disorder (ADHD) as a
prepubescent child, which he thinks may explain his inability to focus in class and his
reoccurring outburst then.
Furthermore, the patient explained that, in relation to the first session, he had frequent
problems in his relationships with other people, both men and women, but not his parents,
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sometimes getting into conflict with his coworkers and friends. More importantly, B.H admits
that he now recognizes these issues, primarily his irregular behavior and his lack of constraint,
yet, it was this past year that pushed him to the brink, after losing both his job and his partner.
Following the first session, it had already became clear that BPD was unlikely diagnosis for B.H,
and that he displayed patterns of behavior in line with manic episodes, where the patient acted
erratically without any consideration for the ramifications of his erratic behavior. Thus, it was
predetermined that the second interview would include the MINI, which is a short structured
diagnostic interview, developed jointly by psychiatrists and clinicians in the United States and
Europe, for DSM-IV and ICD-10 psychiatric disorders.
Third Interview
The third interview was intended to exclude BPD as a differential diagnosis, as B.H did
not seem to fit the diagnostic criteria for the disorder. Hence, the third interview was solely used
to administer the Structured Clinical Interview for DSM Axis II disorders (SCID-II) (2). The
administration of the interview lasted approximately 20 minutes, and following the
administration of the SCID-II, the patient was informed on the nature of the fourth and final
interview.
Final Interview
The fourth and final interview conducted with the patient was concerned with the
administration of the clinician version of the Structured Clinical Interview for DSM 5 Disorders
(SCID-5-CV) (3). The goal of administering the SCID-5-CV was to determine if B.H does
indeed fit the diagnostic criteria for (BD-I). The interview lasted for around 40 minutes, and
afterwards, B.H was informed that this was the final session, and he was instructed to ask any
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questions or voice any concerns that he may have regarding the usage of his information for the
purpose of this diagnostic case study.
Diagnostic Assessments
Mini International Neuropsychiatric Interview (MINI) (Sheehan et al., 1998)
The Mini-International Neuropsychiatric Interview (MINI) is a short structured diagnostic
interview, developed jointly by psychiatrists and clinicians in the United States and Europe, for
DSM-IV and ICD-10 psychiatric disorders (Sheehan et al., 1998). With an administration time of
approximately 15 minutes, it was designed to meet the need for a short but accurate structured
psychiatric interview for multicenter clinical trials and epidemiology studies and to be used as a
first step in outcome tracking in non-research clinical settings (Sheehan et al., 1998). Thus, the
MINI is short, simple, clear, specific, and more importantly, highly sensitive, meaning that the
MINI has the ability to detect most patients with a mental disorder. It is worth noting that the
authors did not only develop the MINI., but also its family of interviews: the MINI-Screen, the
MINI-Plus, and the MINI-Kid, yet, none of the other interviews were administered to the patient.
Structured Clinical Interview for DSM-IV Axis II disorders (SCID-II) (First et al., 1997)
The Structured Clinical Interview for DSM-IV (First et al., 1997) is a semi-structured clinical
interview administered by trained clinicians and designed to yield psychiatric diagnoses
consistent with DSM-IV/DSM-IV-TR) diagnostic criteria. The duration of administration ranges
between 15 min and 2 h. The SCID is designed to begin with open-ended questions that
introduce each content area (e.g., “Have you ever had…?”), followed by a series of scripted
questions to be asked verbatim. At the close of each module, the SCID directs interviewers to
append as many additional questions as needed in order to be confident about the validity of their
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ratings. The SCID-II differs from other personality interviews in several respects. Although other
interviews have a disorder-based format available, only the SCID-II has this format as its
primary (and only) format of administration. First et al. (1997) maintain that the grouping of
questions based on disorder may more closely approximate clinical diagnostic practice and that
this grouping forces interviewers to consider criteria in the context of the overarching theme of
the disorder. The SCID-II has shown reliability comparable to other interviews and has been
used in a number of studies (First et al., 1997).
Structured Clinical Interview for DSM-V-Clinical Version (SCID-5-CV) (First et al., 2014)
The Structured Clinical Interview for DSM-V Disorders—Clinician Version (SCID-5-CV)
guides the clinician step-by-step through the DSM-5 diagnostic process. Interview questions are
provided conveniently alongside each corresponding DSM-5 criterion, to aid in rating each
criterion as either present or absent (First et al., 2014). A unique and valuable tool, the SCID-5CV covers the DSM-5 diagnoses most commonly seen in clinical settings. The User's Guide for
the SC/D-5-CV provides comprehensive instructions on how to use the SCID-5-CV effectively
and accurately. It not only describes the rationale, structure, conventions, and usage of the SCID5-CV, but also discusses in detail how to interpret and apply the specific DSM-5 criteria for each
of the disorders included in the SCID-5-CV (First et al., 2014). A number of sample role-play
and homework cases are also included to help clinicians learn how to use the SCID-5-CV.
Together with the SCID-5-CV, the User's Guide for the SCID-5-CV proves invaluable to
clinicians, researchers, interviewers, and students in the mental health professions who seek to
integrate time-tested interview questions corresponding to the DSM-5 criteria into their DSM-5
diagnostic assessment process.
Diagnostic Assessments’ Results
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The first diagnostic test administered was the MINI, and the results obtained from the
MINI strongly suggested that the B.H did meet the diagnostic criteria for a current major
depressive episode and a past manic episode, whereas no other criteria was met for the examined
disorders and illnesses. Moreover, the results from the second diagnostic test, the SCID-II,
showed that B.H did not fit the diagnostic criteria for BPD which is in contrast to what his GP
believed before referral. Finally, based on the results of the SCID-5-CV, it appeared that the
patient, yet again, had met the diagnostic criteria for a current major depressive episode as well
as a past manic episode, which are the two facets comprising BD-I.
Proposed Diagnosis
Firstly, after the initial interview, it was evident that B.H did not exhibit many symptoms
of BPD, almost none in fact. To elaborate, symptoms of BPD include a pattern of unstable
relationships, a fear of abandonment, rapid changes in self-identity, impulsive and risky
behavior, ongoing feelings of emptiness, intense and often displaced anger, suicidal ideation and
attempts, and mood swings, typically lasting from a few minutes to a few hours (Gunderson,
2009). In hindsight, it would appear the B.H fits some of the criteria for BPD, namely the
impulsive behavior, unstable relationships, and suicidal ideation. One may also argue that, when
B.H abandoned his then pregnant former partner and his unborn child, the patient was acting on
his fear of abandonment, which often leads to BPD patients taking extreme measures to avoid
abandonment, such as abandoning an individual first before that individual is able to abandon
them. Yet, after the series of interviews and diagnostic tests, it was the clinician's conclusion that
BPD was nothing more than a differential diagnosis, one which was eventually excluded in light
of the results from the SCID-II and the SCID-5-CV respectively.
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On the other hand, following the second interview, which was an anamnestic interview
antecede by the MINI, it had become apparent that the clinician’s focus should be to label BPD
as a differential diagnosis and to place BD-I as the primary clinical diagnosis under
investigation. The reason for such a decision on the clinician’s side was influenced by the
patient’s medical history, anamnesis, and the results from the MINI, as the diagnostic test
suggested that the patient may fit the diagnostic criteria for BD-I. BD-I is characterized by two
main facets, mania and major depression, with the latter not being a necessity as opposed to the
former (Müller-Oerlinghausen et al., 2002), and the symptoms include exceptional energy,
restlessness, trouble focusing, feelings of euphoria, poor judgment, impulsive and risky behavior,
and difficulties with sleep (Müller-Oerlinghausen et al., 2002). Following the third session, after
the administration of the SCID-II, it became more likely that BPD should not be the primary
focus of clinical assessment, and after the final session, specifically after the administration of
the SCID-5-CV, it was certain that B.H both displayed symptoms of BD-I and fit the diagnostic
criteria for the disorder as well.
However, the question, as to why the patient’s GP saw BPD as a possible diagnosis for
B.H, still stands. The answer to this question is rather simple; BPD and BD-I are commonly
confused in diagnosis as, in a snapshot, the two mental disorders may look similar (Paris, 2004).
Both disorders are, in particular, characterized with impulsive behavior, intense emotions, and
suicidal ideation (Gunderson, 2009; Müller-Oerlinghausen et al., 2002). Yet, this shortsighted
snapshot is not the best way to distinguish between the two disorders, as in a snapshot, patients
with different diagnoses may appear to have similar symptoms, leading a mental health
professional to an eventual misdiagnosis. Moreover, a patient’s symptoms may change over
time, sometimes even decreasing or increasing in intensity, which ultimately affects the
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diagnosis a patient receives. Undoubtedly, a characteristic that strongly distinguishes BD-I from
BPD is the mania, as BPD is not characterized by any manic symptoms, or hypomanic for that
matter, which presents a strong case for the patient, as the patient’s impulsivity and reckless
behavior, manifested in his relationships and alcohol abuse, is more closely correlated to
episodes of mania, as opposed to the impulsive behavior demonstrated by many BPD patients.
Conclusion
BD-I is amongst some of the most challenging disorders, as patients with the disorder
face difficulties in daily life and basic functioning. The prevalence of BD-I is fairly significant,
and sadly, since the causes of the illness are not well-known, there are currently no studied
preventative strategies for the disorder. Nonetheless, the disorder may be managed and treated
through a variety of effective methods, ranging from therapy to medication. This paper was
concerned with the presentation of a recent diagnostic case study of a patient who exhibits
symptoms which fit the diagnostic criteria for BD-I in the DSM-V. After a series of four
interviews, including three diagnostic assessments, a case report was formulated based on the
information provided by the client, the results of the diagnostic tests, and the clinician’s expertise
and interpretation. All in all, the purpose of this paper was to investigate the client’s concerns in
an effort to assign a preliminary diagnosis to the client, and certainly, both purposes were met.
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References
Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of
Medicine, 383(1), 58-66.
First, M. B., Gibbon, M., Spitzer, R. L. Williams, J. B. W., & Benjamin, L. S. (1997). Structured
clinical interview for DSM-IV axis II personality disorders, (SCID-II). Washington, DC:
American Psychiatric Association.
First, M. B. (2014). Structured clinical interview for the DSM (SCID). The encyclopedia of
clinical psychology, 1-6.
Gunderson, J. G. (2009). Borderline personality disorder: A clinical guide. American Psychiatric
Pub.
Müller-Oerlinghausen, B., Berghöfer, A., & Bauer, M. (2002). Bipolar disorder. The Lancet,
359(9302), 241-247.
Paris, J. (2004). Borderline or bipolar? Distinguishing borderline personality disorder from
bipolar spectrum disorders. Harvard Review of Psychiatry, 12(3), 140-145.
Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., ... & Dunbar,
G. C. (1998). The Mini-International Neuropsychiatric Interview (MINI): the development
and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10.
Journal of clinical psychiatry, 59(20), 22-33.
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Appendix
(Attached Separately)