Possible Diagnosis
Before describing appropriate treatment for Jack, it is imperative to discuss the possible diagnosis. Based on the symptoms and historical background, Jack likely suffers from two mental disorders: Bipolar disorder, major depressive disorder (MDD), and borderline personality disorder (BPD). Apart from a past diagnosis of bipolar disorder and BPD, the recent loss of her husband and her suicidal ideations hint at possible depression. The DSM-V diagnostic criteria for MDD indicate that for at least two weeks, the patient has been experiencing low mood and sadness accompanied by a loss of interest and pleasure in activities (Morrison, 2014). Although Jack had lost her husband, which can cause depression, she did not express a lack of interest or pleasure in daily activities. Her mood swings cycle between low and elevated moods, more characteristic of mania than depression, based on the DSM-V diagnostic criteria for depression. Therefore, Jack does not fully meet the diagnostic criteria for depression.
She probably has a BPD because of the presenting symptoms, like having problematic relationships with everyone, including her sons and mother. She communicated that the only person she had a good relationship with was her late husband. According to the DSM-V diagnostic criteria for BPD, people with this disorder often have problems with self-image, and they mostly excessively attach themselves to other people. Even slight mistreatment or being ignored by such people can result in a perpetual crisis in mood or behavior (Morrison, 2014). Indeed, Jack verbalized that she feels she is a tomboy, a clear indication of a disturbed self-image. Besides, she has a family history of BPD (her mother is diagnosed with it), a known risk factor for this mental disorder (Morrison, 2014).
Besides BPD, Jack still has a probable diagnosis of Bipolar Disorder I. According to Morrison (2014), a person can be diagnosed with two or more mental disorders under the conventions of DSM-V if they both belong to different domains of psychological function. For example, BPD is a personality disorder, whereas Bipolar Disorder I is a mood disorder; they can coexist. However, when making such a diagnosis, it is crucial to focus on the condition that contributes the most to the current situation.
Although Jack was diagnosed with BPD one year ago, DSM-V recommends being careful because the interpersonal relationship and self-image problems could be functional difficulties associated with mania (Morrison, 2014). For instance, a diagnosis of BPD requires that the patient experienced marked impulsivity beginning by early adulthood besides having symptoms like disturbed self-image. Besides, Jack does not meet at least five criteria for BPD diagnosis as recommended by DMS-V. Therefore, it can be concluded that difficulties in interpersonal relationships, inability to work, drug abuse (addiction to painkillers), and disturbed self-image are consequences of Bipolar I. The specific diagnosis, in this case, is “mixed states,” as evidenced by the alternating episodes of mania and depression (Berzoff et al., 2021). Berzoff et al. (2021) added that “mixed states” is characterized by sleeping difficulties and suicidal thinking, which were also present in Jack. Early-onset Bipolar I Disorder has been found to progress persistently to adulthood (Boland et al., 2017). Jack was diagnosed with Bipolar I Disorder in her late teens, which might have persisted until to date, especially considering that she does not comply with mood stabilizer medications (lithium).
In summary, Jack can be diagnosed with mixed states (manic episodes plus depression). Remarkably, her mania can be interpreted as severe because it has significantly interfered with her functioning, as evidenced by not working, strained social relationships with friends and family, and addictive tendencies (i.e., addiction to painkillers). She is also mood incongruent. However, she does not have any psychotic episodes. Two diagnostic codes can be assigned in this case, namely F31.13 [296.43] for severe mania and F31.4 [296.53] for the alternating bouts of depression related to being manic (Morrison, 2014). Her treatment is discussed below.
Untreated manic episodes can persist over a long period, causing many breakdowns in the lives of the patients and their friends and family in the form of lost jobs and other pieces gathering together (Berzoff et al., 2021). Mood stabilizers like lithium are highly recommended in the clinical treatment of Bipolar I. Unfortunately, Jack does not comply with the drug, which is why she has these recurrent episodes of mania and depression. Apart from lithium, psychotherapy has also been recommended for treating mood disorders like Bipolar I (Berzoff et al., 2021). The clinical social worker can find out why Jack refuses to take the drug, especially considering the good therapeutic and professional relationship between the two, marked with high levels of trust. After establishing the cause, the social worker can provide tailored psychoeducation to address underlying issues.
In the meantime, the social worker can also provide other treatment modalities, mainly psychotherapy. Above all, the social worker should provide psychosocial intervention to mend the problems that have already occurred, such as strained interpersonal relationships with friends and family, employment, and painkiller addiction (Boland et al., 2017). Even if Jack agrees to take medication, multimodal therapy comprising pharmacotherapy, psychotherapy, and psychosocial intervention can effectively address the underlying issues (Boland et al., 2017).
The new diagnosis of Bipolar I Disorder means that Jack must abandon treatment modalities for BPD. It also means that Jack must resume lithium medication under her informed consent. Since psychosocial issues like painkiller addiction, strained interpersonal relationships (e.g., with sons), and unemployment have intensified in the recent past, new psychosocial interventions must be tried. Therefore, the new diagnoses will completely change her course of treatment because interventions like cognitive behavioral therapy are tailored to meet patient needs. Before recommending specific treatment modalities suitable for these new diagnoses, it is imperative to outline some bio-psycho-social factors that a clinical social worker needs to know first.
Bio-Psycho-Social Factors
Assessing the biopsychosocial factors contributing to the patient’s mental problems is critical to patient-centered care in clinical social work (Boland et al., 2017). Social workers should take time with the client to collect as much information as possible to help determine biopsychosocial factors. The main biological factor in the case study is Jack’s familial predisposition to BPD. Her mother is currently diagnosed with BPD. Since she has begun to portray some symptoms of BPD, although not yet at a clinical threshold, the clinical social worker should closely monitor her by addressing psychosocial issues. When developing etiologic factors for a patient’s condition, the clinical social worker should screen for any neuromotor, physical, and developmental abnormalities (Boland et al., 2017). Some exceptions that can contribute to the development of Bipolar I include brain development abnormalities and neuroplasticity (Berzoff et al., 2021; Boland et al., 2017). Bipolar I disorder also runs in families (Morrison, 2014). The case study does not provide information such as whether Jack’s father had any mental illness and thus must be gathered.
The main psychological factor implied in the case study is painkiller addiction. There is no information about what she is trying to cure using painkillers. She could be suffering from a substance use disorder. However, according to Morrison (2014), substance use disorder can only be diagnosed if an individual has used the substance long enough to produce clinically significant distress or impaired functioning. From the information provided in the case study, it is unclear how much harm the painkiller addiction has caused Jack. For example, respiratory system depression, vomiting, and nausea due to opioid addiction can cause severe damage to the patient’s functioning. Therefore, the painkillers, quantity and frequency of consumption and any functional impairment will be assessed to provide more patient-centered care.
Apart from painkiller addiction, another psychological factor is coping with her current situation. Jack verbalized to the clinical social worker about suicidal ideations because she could not cope with staying with her mother. Her suicidal ideations are indicative of maladaptive coping with her situation. Besides, some of the information not provided in the case study is the stress level, and loss Jack’s condition caused to her family. Some individuals that need to be included in her treatment have her two sons. Family members of people with mental problems are often reported with significant psychological distress requiring clinical intervention (Boland et al., 2017). If it is found that they suffer distress, appropriate evidence-based psychosocial intervention should be implemented to help the family members to cope.
Finally, much information provided in the case study is about Jack’s social functioning. First, she is experiencing strained social relationships with everyone, including her mother and, recently, two sons. A comprehensive treatment plan, including family therapy, is recommended (Boland et al., 2017). Another social issue is chronic unemployment. Psychosocial interventions are also needed to solve the problem.
Conclusion
In conclusion, Jack can be diagnosed with Bipolar I Disorder based on the DSM-V diagnostic criteria. She appears to have symptoms of BPD but does not meet a clinical threshold. It suggests that some symptoms of BPD could be associated with severe, mixed-state Bipolar I without psychosis. Since she does not take lithium, a comprehensive treatment plan comprising individual and family sessions is required. A range of issues to be addressed includes strained social relationships and unemployment.
